Monday, April 1, 2013
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?
Posted by Doug Capra at 1:17 AM