Monday, April 1, 2013

Inappropriate Touching in the Doctors Office

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? 


Joel Sherman MD said...

I went through training a generation before Dr. Ubel. Although my first year was mainly medical, I did have one surgical rotation where I once performed a pelvic exam prior to a hysterectomy at the behest of the surgeon while the patient was under anesthesia. I have no idea if the patient's permission was asked beforehand, though I doubt it very much. Informed consent was just not a big topic of interest in the late 60's. As I was an intern helping in the lady's care (not a medical student doing the exam only as a learning experience) the exam was justifiable. That doesn't mean though that it's ever proper to do an intimate exam without permission. Hopefully this practice is disappearing everywhere now.
Dr. Ubel is certainly correct that a pelvic exam under anesthesia is much easier; the ability to feel pathology is definitely increased, especially for inexperienced examiners. It is however not that hard to obtain permission for exams when the attending physician asks beforehand. Many patients will agree and they are doing students a great service as it can be difficult for students to gain the necessary experience. It's in everyone's long term interest to improve medical teaching.

Maurice Bernstein, M.D. said...

Dr. Ubel's final question:"How can an ethics lecture compete with a palpable uterine mass?" Must the ethics lecture or ethics compete?

Ethics, as taught in an ethics lecture, should be consider a "tool". Think of ethics like a microscope used as tool to diagnose cells in a bit of tissue. Ethics becomes a tool to make a decision whether a medical student as described in the scenario experiencing that mass represents a moral good or a moral bad. And using ethics as a tool, one must weigh one ethical principle against another and compare the "good" and the "bad" as applied to the stakeholders: to the student, to the patient herself, to medical education in general, to all females or society in general and associated laws. Unfortunately for unanimity, the weighing (prioritizing of principles) may end up being specific to the interests of the particular stakeholder.

Like so many other ethical issues, some become dilemmas because each of the principles seem most important to that stakeholder but yet a final conclusion must be made. Thus the decision is often based not on the conclusion of one individual but on a consensus of different individuals who are utilizing the "tool" of ethics.

At the present, I understand that the consensus regarding the ethics of students performing pelvic exams on anesthetized women without the permission of the woman is unethical. It is not about the student learning how to perform a pelvic exam of value but about the right of the woman to give permission or reject that examination. So you see, the ethical consensus in this example is not "competing" but actually supporting the woman's autonomous right to select those who she approves to enter her vagina and feel for that mass. ..Maurice.

Doug Capra said...

Maurice, et. al.

One of the issues Dr. Ubel writes about is the whole idea of informed consent. How do we define it? From a philosophical point of view, are there basic human rights absolutes that transcend contexts and situations? Or, is all situation ethics?
I mention this in terms of your comment: "At the present, I understand that the consensus regarding the ethics of students performing pelvic exams on anesthetized women without the permission of the woman is unethical." Is this situation ethics, or is basic informed consent an absolute regarding this kind of behavior with anesthetized women?
Was this behavior "ethical" years ago because it was a consensus reached by some of the stakeholders? I say "some" because, it seems to me, this is an integral question. Is it required that patients be part of reaching this consensus? What if an individual patient disagrees with the consensus? Does that patient have a right to treatment that coincides with his or her values system? What other aspects of informed consent should we be talking about regarding Maurice, et. al.

One of the issues Dr. Ubel writes about is the whole idea of informed consent. How do we define it. From a philosophical point of view, are there basic human rights absolutes that transcend contexts and situations? Or, is all situation ethics?
I mention this in terms of your comment: "At the present, I understand that the consensus regarding the ethics of students performing pelvic exams on anesthetized women without the permission of the woman is unethical." Is this situation ethics, or is basic informed consent an absolute regarding this kind of behavior anesthetized patients of either gender? Some posters on your and our blog complain that they weren't informed that they would have a foley cath inserted during an operation, and were angry later when they found out. Their values required that a male nurse do the procedure?
Just some questions. I'd be interested in hearing form Dr. Ubel as well as you, Maurice, and Joel and any others regarding these and other questions about informed consent.

Anonymous said...

This issue can be dissected, compilated and appraised
endlessly. The fact that as long as it dosen't happen to
the "physicians family" then its irrelevant. The equivalent mentality exists in most of these other discussions.


Maurice Bernstein, M.D. said...

Doug, "informed consent" is a property of the ethical principle of autonomy. Decades ago, patient autonomy was only a glimmer, if even present, overwhelmed by physician paternalism. At that time, patient beneficence was set by consensus of society as the outcome of allowing doctors to make the medical decisions. Times have changed and now patient autonomy trumps physician paternalism. Yes, even the insertion of a Foley urethral catheter during surgery and present when the patient awakens should be part of the informed consent prior to surgery where the surgeon explains to the patient not only the surgery but also post-operative status, what the patient will experience on awakening. If the time is taken for proper communication with the patient, the patient should experience no surprises. Ethics decisions are situational in that facts of the situation should shape the decisions but are also may be generational, views changing with time.

And PT, don't believe that "physician's family" are immune to the experiences of all the other patients. ..Maurice.

Medical Patient Modesty said...

It’s unethical to do pelvic, rectal, and genital exams on patients under anesthesia without their consent. The truth is many patients would not consent to medical students doing those types of exams on them. Many patients value their privacy and modesty. Patient’s wishes should always be number 1 priority.

I personally think that medical schools should change their requirements and cut down on the number of pelvic, genital, and rectal exams for the sake of patients’ wishes for privacy and modesty. There is no reason for medical students who are planning on going into specialties such as cardiology, orthopedics, neurology, rheumatology, ENT, ophthalmology, etc. to be required to be skilled in doing pelvic, genital, and rectal exams. Doctors in those specialties do not do any invasive exams. I understand some medical students are not sure what specialty they want to go into. But many medical students already know what they want to specialize in. Some medical students such as the stressed medical student left medical school because she had strong convictions that she should not do any genital, pelvic, or rectal exams. That medical school should have waived the requirements for her since she was planning on going into a specialty that did not require her to do those exams.


Medical Patient Modesty said...

I wanted to share several more concerns.

1.) Other problems with non-consensual pelvic exams are the possibilities of injuries to the cervix at the hands of some of the clumsier students and the risk of infection or the possibility of internal injuries due to the slip of an instrument. This is exactly why medical schools should change their requirements for medical students to do pelvic exams on women. There is no reason for medical students who are going into specialties that will not require gynecological examinations to be required to practice pelvic exams in medical schools.

2.) I have a feeling that this surgeon performed a hysterectomy on the woman Dr. Ubel did a pelvic exam on. About 85% to 90% of hysterectomies are actually unnecessary. I did a lot of research on hysterectomy recently and I was very disturbed to learn about many consequences of hysterectomies that women are often not informed of. We need to work on cutting the rate of hysterectomies in the US. Check out Why Hysterectomies Are Often Unnecessary? Also, many women are not informed that their bladder could be perforated during hysterectomy. The standard of care calls for bladder perforations to be identified in surgery and repaired while the patient is still under anesthesia. The repair of bladder perforation can either be done vaginally or through an open abdominal surgery. Whichever technique is used, an urologist or urogynecologist will be called into the operating room to perform the repair. This means that a woman’s gynecologist could call in an urologist while she is under anesthesia without her consent. Most urologists are male. This is a concern for a woman who only wants an all-female team.


Anonymous said...

Dr. Ubel,

I can easily understand why you did it when told to. This is something that has been proven by the classic experiment done by Milgram about people following authority without question. Interestingly, that experiment itself raised a lot of issues about the ethics of people participating in studies.

Anonymous said...

"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."

One has to wonder if in 6 short weeks their 'moral attitudes" were changed, or simply: the belief that they are somehow beyond the scope of moral actions to which normal society is held accountable.

Either way...a bit troubling.


Medical Patient Modesty said...

Anonymous on June 12, 2013 brought up some very interesting points. I am sure that there are many medical students who were very uncomfortable with the idea of doing non-consensual intimate examination on patients, but they felt they had to give in because they felt threatened that if they did not follow the professor’s orders that they would not pass medical school. It is hard to question authority sometimes. I knew of a conservative Christian guy who was very upset in nursing school when he was told that he would have to do a breast examination on a woman. That went against his convictions.

Anonymous said...

Dr. Ubel, and especially the unnamed patient upon whom he admitted on a public forum committing battery, might be interested in reading "Using tort law to secure patient dignity." The article pops right up if you Google the title.

Doctor Watchdog

Anonymous said...

As a lawyer, reading this blog is more than a little troubling. I'd first like to thank Dr. Sherman for standing up for patients.

Doctors and medical professionals always seem to forget that informed consent is more than a mere ethical suggestion; its the LAW. Informed consent is first and foremost a legal doctrine to protect patients from harmful touching. Doctors do not have the "right" to touch any patient. The patient allows the doctor the privilege of touching him/her through consent. Once consent is revoked, the doctor is no longer legally allowed to touch the patient. Most states, if not every state, have statutes defining informed consent. If no statute exists, the common law definition applies.

Pelvic exams on anesthetized patients without their informed consent is not only the tort of battery, as Doctor Watchdog pointed out, it is also criminal assault. In fact, California expressly criminalized this act in 2004 in response to the rampant abuse of unconscious women. The point is that you MUST obtain informed consent to touch a patient. The patient's consent does NOT extend to unknown personnel. You MUST inform her, and she absolutely has the ability to limit her consent. She may not know the names of every nurse, etc, but she recognizes they will be there and what they do. Anyone doing ANY kind of offensive touching to an intimate area must get consent. For example, if a woman is having a hysterectomy, she should expect the treating physician and possibly even the resident she actually met to do a pelvic while she is under. This is reasonable and clearly a necessary, expected part of her care. She does NOT consent to med student Joe, who she has no clue even exists, touching her private areas, especially since it has nothing at all to do with her medical care. See the difference?

Now there may be rare situations where emergencies arise, such as Misty's example, where the doctors cannot get the patient's consent. This is treated differently under the eyes of the law, but a patient still may have a successful lawsuit if the risk was never revealed to her or for a variety of other reasons.

The power lies with SOLELY the patient, and her consent must be knowledgeable and voluntary. Coercion and duress are also legal doctrines that vitiate informed consent; doctors as fiduciaries are held to higher standards and presumed to exert more influence over patients due to their knowledge.

If anyone feels he/she has been inappropriately touched by any medical provider, I strongly urge you to contact a lawyer. Specifically speak with the lawyer about filing criminal charges. Believe it or not, many of us actually care about people, especially our clients.

And quite frankly, I find it absolutely disgusting that many doctors treat low income patients with less dignity and respect. I have personally experienced how a doctor completely changes his attitude, decorum, word choices, and even took a few steps back from me after finding out I am a litigator. All doctors must treat all patients with respect and abide by the law.