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Gynecology

 
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Tehanu
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PostPosted: Fri Jan 29, 2010 2:25 am    Post subject: Gynecology Reply with quote

Let's start this off with a story that is incredibly cringe-worthy. In Canada, there is nothing to prevent teaching hospitals from performing gynecological examinations on women who are under general anesthesia for surgery. Without informing the women that they are doing so. Because, hey, they're unconscious, and medical students may not have the chance otherwise.

Guidelines on this in Canada, unlike the USA and Britain, state that consent is "implicit."

What?!?!

And it took a medical student to point out that this might be unethical?

I love hearing about how an unconscious woman has given implicit consent to having her genitals, vagina and cervix touched by strangers.

Quote:
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.

Do you consider this okay, or an outrageous violation of your rights?

Regardless of your feelings, you should be aware that this is standard procedure in many Canadian teaching hospitals.

... Guidelines in the United States and Britain say specific consent is required but, by contrast, Canadian guidelines state that pelvic examination by trainees is implicit.

The practice one of those dirty little secrets of medicine has been exposed in a thoughtful, professional manner by a young doctor.

The story goes back to 2007 when Sara Wainberg was a medical student at McMaster University. Her younger brother Daniel, also studying to be a doctor, phoned for advice: As part of his rotation in obstetrics and gynecology, he had been asked to perform a pelvic exam on a woman who was under anesthetic. He refused, saying doing so without consent would be unethical.

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.

She polled her fellow students and found 72 per cent had also done exams on unconscious patients, without consent, confirming that it is routine.

... Dr. Wainberg and her team found that fewer than one in five women were aware that a student might do a pelvic exam in the operating room. At the same time, 72 per cent expected to be asked for consent before such an exam was done.

... The most intriguing part of the survey, though, is that it showed that women are quite willing to undergo these gynecological exams if they're asked.

... This lays to rest the notion that it would be impossible for medical students to get this training unless they were doing it in the current surreptitious, unethical manner.

But let's be clear: Even if all the women surveyed had rejected exams by medical students, the current approach would still be wrong.


Globe and Mail (via Feministing)

I particularly like this comment on the article:

Quote:
1/28/2010 10:29:23 AM

It is essential for medical students to learn basic techniques, including pelvic examination, in well supervised settings
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It is essential for medical students to learn medical ethics, including obtaining informed consent, in well supervised settings
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Cartman
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PostPosted: Fri Jan 29, 2010 4:55 am    Post subject: Reply with quote

Unfuckingreal!
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Cartman
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PostPosted: Fri Jan 29, 2010 5:21 pm    Post subject: Reply with quote

I am surprised that this thread is not more active. That in itself speaks volumes. If this were a story about med students probing men's bumholios, doing bag inspections, or diggin into penis holes in front of others without their explicit consent, I suspect that it would be more active. I wonder if their are laws about that? I suspect that a rape victim learning of how she had been used as a medical toy would feel doubly violated.

TS should dig probe look into inquire into this for us further. He is gonna know more about the law than he ever wanted to.
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TS.
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PostPosted: Fri Jan 29, 2010 6:30 pm    Post subject: Reply with quote

I've taken a quick search and I can't quickly find a statute or court decision on this subject.
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Dimitrios Makropoulos
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PostPosted: Fri Jan 29, 2010 7:22 pm    Post subject: Reply with quote

Cartman wrote:
I am surprised that this thread is not more active.

I cant speak for others, but the facts, as outlined in the posted story, is so breathtakingly incredible no coherent response springs to mind.

But if lack of a response is being interpreted as a lack of concern: Sweet suffering Succubi!
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Hephaestion
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PostPosted: Fri Jan 29, 2010 8:10 pm    Post subject: Reply with quote

Well, this is just all MANNER of fuqued up... what's particularly perplexing (to me) is that the woman in the OP had never thought about it as unethical, until her brother brought it up! What the hell, are we just chunks of animated meat to some of these people?!
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Tehanu
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PostPosted: Fri Jan 29, 2010 9:44 pm    Post subject: Reply with quote

Not only the woman who wrote the article, but a whole series of medical students and even more troubling, doctors teaching those medical students, over and over in teaching hospitals across the country.

I've been reading the comments on that Globe article and a number of medical folks are chiming in with pseudo-justifications that totally miss the main point. In general, they can be boiled down to:

-- This type of surgery involves a pelvic examination anyway, so it's already being done, it doesn't matter if it's done again by a medical student. That they themselves have not seen a parade of medical students lining up to insert speculums (specula?) just maybe one or two. [Presumably that makes a difference in the ethics of obtaining consent, somehow?]

-- This is no different from moving an arm, palpating an intestine, feeling a tumour, etc., etc., all of which medical students may do during surgery and none of which has explicit consent either (a.k.a. Heph's "piece of meat" point).

-- You [ignorant] laypeople really need to understand that us [godlike] medical people are good, caring, dedicated folks who just want to make your lives better, so back off.

But no. The point is that additional pelvic examinations for the purposes of teaching medical students are not medically necessary for the woman involved. And in effect, her unconscious body is doing them a favour in helping them to learn. Which she herself has not consented to.

If all of what these medicos are asserting is true, then explain it to the woman before she goes under anasthesia, and fucking ask her if it's okay. I can say, honestly, that I wouldn't have a problem with it, although I'd be MUCH more inclined to volunteer to have them do it when I am awake and I can actually, oh, say, tell them if they're hurting me.

Pieces of meat, indeed.
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mamitalinda
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PostPosted: Fri Jan 29, 2010 10:05 pm    Post subject: Reply with quote

I remember hearing a med student I know complain that a patient with a micropenis wouldn't let her and a few classmates in to look at his junk. She was offended, and dismissive. "How else are we supposed to learn?" she asked.

Like the guy doesn't have enough problems without having a bunch of med students treat him like a curiosity. Christ, have they never heard of Google?
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Cartman
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PostPosted: Fri Jan 29, 2010 10:14 pm    Post subject: Reply with quote

A friend of mine made a good point. She said it was most disturbing, as a university student, to think that she might be out with some friends at the University pub, only to see a medical student she knows, and start thinking about a previous medical procedure. Whether they might be talking about her or not, it might be most humiliating. Are they giggling about my body?

Is consent really that difficult to request? What would be the problems of asking for as much?
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Dimitrios Makropoulos
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PostPosted: Sat Jan 30, 2010 9:25 pm    Post subject: Reply with quote

If the surgery is scheduled, what is stopping the hospital from getting a request form, listing those medical students who wish to be permitted to do a physical examination. Then the patient can go through the list and either turn the request down in total, or accept and decline on a student by student basis.

We already know from the story that the majority of women would give permission were it requested.

This seems a blatantly obvious procedure, once one gets over the shock of their current practise.
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Senor Magoo
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PostPosted: Mon Feb 01, 2010 6:36 pm    Post subject: Reply with quote

That seems reasonable, except for the part about cherrypicking the list. If only half of a class of new doctors receives full training in a procedure, that's bad on face value, but could also open the school up to appeals or lawsuits.
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TS.
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PostPosted: Mon Feb 01, 2010 8:44 pm    Post subject: Reply with quote

There has to be another way. It is not acceptable to be touching someone's genitals without their express consent.
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Tehanu
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PostPosted: Mon Feb 01, 2010 8:57 pm    Post subject: Reply with quote

Other ways:

-- Get informed consent before surgery
-- See if the woman would be willing to be examined while conscious (better)
-- Ask for volunteer "patients" and/or pay people to come in as "models"
-- Use plastic models

All of which I understand are common practices in medical schools and teaching hospitals.
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Tehanu
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PostPosted: Mon Feb 01, 2010 9:08 pm    Post subject: Reply with quote

The Globe did a follow-up editorial:

Quote:
... In a pelvic exam, a woman's vulva, vagina, uterus and rectum are probed digitally and by a speculum, a plastic or metal-hinged instrument shaped like a duck's bill. It is important that medical students learn how to do the examinations. But not at the price of patient autonomy.

Officially, those responsible for training the next generation do not want it to happen. Vyta Senikas, the associate executive vice-president of the Society of Obstetricians and Gynecologists, says she doubts it is happening. If that is so, the society should not be reluctant to rewrite its wishy-washy guidelines, which say direct consent is not needed for trainees to do pelvic exams:

... Patients at teaching hospitals receive a higher standard of care in return for accepting the participation of trainees. But when patients are unconscious, and exams are intimate, there should be an onus on the medical profession to obtain clear, specific consent.

In the U.S., national guidelines leave no room for confusion. Some procedures, such as pelvic examinations, require specific consent. Similarly, in the U.K., in cases where pelvic examination under anesthesia is regarded as being of educational value, written consent must be obtained from the woman before she comes to the operating theatre.

Implied consent is a useful fiction; Canadian medicine seems reluctant to part with it. In these circumstances, intimate exams on unknowing patients may amount to a criminal assault.


Some of the comments are predictably appalling.
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Vundo Draxon
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PostPosted: Tue Feb 02, 2010 3:31 am    Post subject: Reply with quote

Dimitrios Makropoulos wrote:
If the surgery is scheduled, what is stopping the hospital from getting a request form, listing those medical students who wish to be permitted to do a physical examination. Then the patient can go through the list and either turn the request down in total, or accept and decline on a student by student basis.

We already know from the story that the majority of women would give permission were it requested.

This seems a blatantly obvious procedure, once one gets over the shock of their current practise.


I agree with Magoo, giving patients the option to discriminate is a bad idea. Patients should have the option of giving consent to any student, or to no students. There should be no provisions for patients to say yes EXCEPT if the student is male/female/dark-skinned/Muslim/etc.

What I find really appalling is that there seems to be NO LACK WHATSOEVER of people who would consent if asked. This would be an entirely different issue if it was actually difficult to find willing patients. Then there might be a debate with two sides, arguments for and against, etc. As it is now, with the abundance of people willing to consent, there are no two sides. There is only one mound of arrogant disrespect towards patients.

I've been using gender neutral terms here because although the focus has been on women, I'd feel the same way as a man. If a doctor asked me if I would be willing to allow students to examine my genitals for the sake of their education I would agree without hesitation. I'd be happy to help. But if I found out they'd been allowed to do this without asking or even telling me it was going on, I'd be absolutely furious.

I can see how some of those comments on the G&M article Tehanu posted could be taken as appalling, but in some ways I think there is a valid point in those what about us guys? comments. Does this "implied consent" BS happen to men just as often? Or is this arrogant disrespect deliberately directed at women?
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mamitalinda
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PostPosted: Tue Feb 02, 2010 2:31 pm    Post subject: Reply with quote

Let's just say if I find out that guys are getting surruptitious rectal exams performed on them while they are under general anaesthetic for another procedure I will be quite surprised.
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Chester
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PostPosted: Tue Feb 02, 2010 4:30 pm    Post subject: Reply with quote

mamitalinda wrote:
Let's just say if I find out that guys are getting surruptitious rectal exams performed on them while they are under general anaesthetic for another procedure I will be quite surprised.
and you can bet your bippy that if it was found that men were regularily getting goosed while under anathesia the outrage would be swift and big.
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Tehanu
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PostPosted: Fri Oct 01, 2010 8:54 pm    Post subject: Reply with quote

May as well put this here, although it's not specifically related to gynecology. However, it does involve a lack of consent related to being anesthetized. Specifically, an anesthetist in Toronto has been charged with 29 counts of sexual assault during surgical procedures. Police suspect there may be more cases as well.

Quote:
Police were first alerted two years ago to a complaint about a Toronto doctor accused of sexually assaulting 29 women, but were unable to pursue the case, CBC News has learned.

Dr. George Doodnaught was charged in March with sexually assaulting three female patients between August 2007 and February 2010 while they were under his care.

Police laid 26 additional charges on Thursday, after 26 more women came forward and accused him of sexual assault.

Doodnaught, 61, worked as an anesthesiologist at Toronto's North York General Hospital.

... Police said the first three assaults they investigated took place while the women were under anesthesia and undergoing surgical procedures in hospital. They believe the other assaults, alleged to have taken place between 1992 and 2010, were carried out under similar circumstances.

... It was not made clear how the victims knew they were abused.

There were no cameras in the operating rooms in the hospital. The hospital's chief of staff, Dr. David White, said in March it was possible for an anesthesiologist to be alone with a patient.

White had also said the police investigation would also examine whether the allegations are the result of vivid dreams that some patients experience as a result of the various medications and types of anesthesia.



CBC [/quote]

Um, okay, is the hospital doing a pre-emptive defence by saying that the women may have been hallucinating? I expect that for sexual assault charges to stick there would need to be a little more evidence than that.

I'm not anti-medicine by any means but I have to say that stories like this particularly make me cringe. Rape is appalling no matter what, but rape/sexual assault when a woman has trusted herself to the medical profession and is drugged is so far removed from "do no harm" it's barely conceivable.
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