How Good Intentions
Turn into Bad Actions
By Peter A. Ubel, M.D.
This article – presented here with the author’s permission -- was first
published in Critical Decisions on
August 9, 2012. Dr. Ubel Is a
physician and behavioral scientist, and Professor of Business and Public Policy
at Duke University. His research
and writing explores the quirks in human nature that influence our lives - the
mixture of rational and irrational forces that affect our health, our happiness
and the way our society functions. It also explores controversial issues about
the role of values and preferences in health care decision making, from
decisions at the bedside to policy decisions. He uses the tools of decision
psychology and behavioral economics to explore topics like informed consent,
shared decision making and health care rationing. In his spare time, he enjoys
classical piano, sports (playing and coaching!), chili peppers and raising two
very active boys. His most recent book, Critical Decisions, came out in the fall of 2012.
I felt a woman’s uterus without her permission.
How this happened, and why I thought I had done the right thing at the time,
tells us something important about medical education and shows us why
doctor/patient interactions often play out like conversations between
earthlings and aliens.
To understand my inappropriate actions, you need
to know something about the physical exams that we physicians conduct on our
patients. More specifically, about the pelvic exams we perform to assess
whether a woman’s uterus or ovaries are potentially diseased.
Almost no one enters medical school with any
skills at examining patients’ bodies. Consequently, the first time medical
students listen to their patients’ hearts, they are lucky to distinguish the
proverbial “lub” from the “dub”—what in technical terms we call the S1 and S2
heart sounds. It takes dozens of listenings before medical students are able to
recognize the existence of a significant heart murmur, and hundreds more before
developing any true expertise and recognizing subtler abnormalities.
And yet, listening to heart sounds pales in
comparison to the difficulties of performing expert pelvic examinations. For
starters, when a medical student listens to a patient’s heart through a
stethoscope, the worst outcome for the patient is the feeling of cold plastic
on their chest. An inexpert pelvic examination, on the other hand, can be
painful for patients. Add to that the sheer uncomfortableness of an even
expertly conducted pelvic exam—this is after all a very private body part being
palpated in a manner that even under experienced hands is usually embarrassing
and unpleasant—and the very act of practicing a pelvic examination feels like a
major intrusion. Any woman willing to let a medical student examine her (before
the more experienced doctors inevitably repeat the examination) is doing the
medical profession a big favor.
Pelvic
examinations differ from heart exams in another important way: they are much
more difficult for medical students to glean information from. An experienced
physician conducting a pelvic examination can discern whether a woman’s uterus
is mal-rotated; whether either of her ovaries is enlarged; and whether
palpation of the uterus causes a woman to experience disproportionate
discomfort, a reaction that could signal underlying pathology. Yet as the
female obstetrician who supervised me during medical school put it to me: “The
first dozen pelvic examinations you perform, you won’t feel a uterus, and you
definitely won’t feel any ovaries; you will just feel warm.”
Indeed, the pelvic examination can be an acutely
uncomfortable portion of the medical encounter for students to learn. We feel
nervous probing women’s private parts; we feel embarrassed at failing to glean
any information from the exam after patients have been kind enough to let us
practice on them.
But we know that we must overcome our nerves and
practice. I certainly knew of my need to practice when I walked into the operating
room that day, in 1987, gowned and gloved and prepared to assist the surgeon in
any way possible, assistance that given my almost complete ignorance of
gynecologic surgery largely would amount to holding a retractor during the
procedure. (A retractor is a medical instrument used to hold back, say, folds
of skin and muscle from the underlying tissues being surgically treated.)
“Student, come over here right now,” the surgeon
said. “We need to start the operation, but you need to examine the patient
first.”
I needed to examine her? I couldn’t see how that
would help anyone. I had never met the patient before, but instead had simply
been told to head over to surgical suite number three, or whatever number suite
it was, to assist in the operation. I hesitated, which only prompted more
urgent beckonings from the surgeon:
“Come over and feel her uterus,” she told me.
“She has a large uterine mass. You need to know how to recognize this kind of
mass on a pelvic exam.”
My confusion was obvious to see, despite the
surgical mask covering the lower half of my face.
“Don’t worry,” the surgeon continued. “She’s
anesthetized and won’t feel a thing. Plus, her muscles are totally relaxed from
the anesthetics, so you will have a much easier time feeling the anatomy.”
I inserted two fingers from my right hand into
her vagina, pressed gently on her abdomen with my left, her uterus now squeezed
between my two hands. Yep. Definite mass. My physical examination skills
were now inching towards expertise. My surgical supervisor had helped me
develop as a physician.
But of course, she’d also shaped my moral
development. I had examined the woman, after all, without her permission. How
could the surgeon and I have thought that it was acceptable to do this? I
could only speak for myself. To begin with, I was frantically obsessed with
learning my new trade. In addition, I wanted to impress the surgeon and
get a good grade on the rotation. So when I stood there in the O.R. that day,
presumably facing a moral dilemma, I barely gave the situation a second
thought.
The result of that was that I began thinking
that this kind of action was ok. The surgeon, after all, was a wonderful
person, committed to medical education and patient care. And I knew that I had
nothing but good intentions in examining this patient. There was nothing
prurient in my behavior. I simply wanted to become a better
clinician.
But I’m sure if we had woken up that woman and
told her what happened, she would have been horrified. The women I have surveyed
on this topic say that, while they’d be willing to give permission for medical
students to practice pelvic examinations on them, they would feel violated if
such practice occurred without their permission.
Moral attitudes are often a function more of our
experience than of our training. When some colleagues and I surveyed medical
students and asked them how important it was to ask permission before
conducting a pelvic exam on an anesthetized woman, brand new medical students
almost universally stated that permission was vital but by the time the
students finished their OB/GYN rotations three years later, they didn’t see
permission as being important anymore. Despite the lectures they’d received
about “informed consent” during the first two years of medical school, six
weeks of an OB/GYN rotation was enough to change their moral attitudes.
How can an ethics lecture compete with a
palpable uterine mass?
