Healthy Skepticism Library item: 17968

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Cloutier-Steele L
Wanted — A Healthy Dose Of Humility And Respect For Patients’ Rights
Redflagsdaily.com 2003 Aug 12

Full text:

A couple of years ago, I watched The Doctor on television, a film starring William Hurt as the most arrogant surgeon you’d ever want to meet. His character was completely devoid of any human compassion for his patients, and he gave them plenty of attitude until he was diagnosed with cancer of the throat and found himself on the receiving end of some of his own medicine. He didn’t like it. His experience brought his ego down a few notches, and he became a better person because of it. I remember thinking at the time that this film ought to be required viewing for all medical students, regardless of the specialty they are training in.

Unfortunately, we may have a long way to go before arrogant attitudes are excised from today’s medicine. This sad reality is confirmed in the results of a study recently published in the American Journal of Obstetrics and Gynecology (2003;188 (2): 575-579). Four hundred and one students from 5 Philadelphia area medical schools were surveyed to determine if the completion of a clerkship in obstetrics and gynecology would make them attribute greater importance to their responsibility of seeking consent for pelvic examinations on anesthetized female patients. The results of the study showed that students who recently completed their clerkship do not think that consent is of any significant importance. The authors of the study, however, concluded that attitudes toward seeking consent could be improved considerably if clerkship directors instructed their students to perform examinations on only those patients who have given their explicit consent. Seems like a good plan, but Ron Cyr, M.D. of Ann Arbor, MI, doesn’t seem to think so.

Dr. Cyr would be a good candidate for retraining in that he wears his arrogance like a badge in his Medscape commentary about the study. Cyr writes: “How specific must a consent be? Can it be verbal, or must it be in writing? Women admitted to a teaching hospital sign an institutional consent acknowledging that they will receive care from students and residents under the supervision of an attending physician. The OR consent usually identifies the responsible surgeon and authorizes such assistants as designated by the surgeon; it also grants permission to videotape or photograph the operation. Patients are normally introduced to medical students and residents prior to surgery and have an opportunity to ask questions before being medicated.”

When I underwent gynecological surgery in 1991, I wasn’t given the opportunity to ask many questions. I was asked to sign a hospital admitting form only, and the secretary in the administration office said I had to be quick about it, because people were waiting for me upstairs. She said the form was merely a formality allowing the hospital to take good care of me, and I signed it promptly. The resident and/or the operating room nurse (there were no formal introductions) said little to me prior to the surgery except maybe where to remove my clothing, and where I’d find them afterwards. Every day I talk to dozens of women whose informed consent was acquired in much the same way, and this does not, by any means, come anywhere close to informed consent. Of course, hindsight is 20:20, and now I know exactly what it should entail.

In early 1998, the CBC’s Marketplace interviewed Dr. Joe Daly, an ob/gyn from Toronto, who spoke candidly about the aftereffects of hysterectomy and ovary removal. Since I couldn’t find an empathetic Ottawa gynecologist to treat my post hysterectomy symptoms, I called Dr. Daly’s office and made an appointment. While my husband and I sat in his waiting room a few weeks later, we overheard his assistant tell a patient that she needed to come back for another appointment before her surgery so that Dr. Daly could go over the informed consent form with her in detail. She then told the patient that she could bring her husband or someone else with her for this appointment. My husband and I turned to look at each other at the same time. We didn’t speak, but the look we gave each other said this: “Now there’s an important step in preoperative care that wasn’t offered to us!” Informed consent begins with doctors, like Dr. Daly, who take their jobs seriously, and who treat their patients with honesty and respect, beginning long before the day of the surgery.

Cyr adds that “it has been more than 25 years since I last witnessed half a dozen students line up to examine a patient purely for education.” Dr. Michael Greger tells it differently in his 1999 book Heart Failure: Diary of a Third-Year Medical Student. Here’s a brief excerpt illustrating that pelvic exams on anesthetized women are still a popular activity at med school. [I am all gloved up, fifth in line. At Tufts University in Boston, medical students – particularly male students – practice pelvic exams on anesthetized women without their consent and without their knowledge. Women come in for surgery and, once they’re asleep, we all gather around; line forms to the left. We learn more than examination skills. Taking advantage of the woman’s vulnerability – as she lay naked on a table unconscious – we learn that patients are tools to exploit for our education. It all started on the first day when the clerkship director described that we were to gain valuable experience doing pelvic exams on women in the operating room. I asked him if the women knew what we were doing. Are the women asked permission? “No,” he said. And not only no, he described that he was “ethically comfortable with that.”]

Dr. Greger’s sensitivity over the issue and his willingness to seek consent from women patients met with great resistance from his director who felt that it would just confuse them. The director said that permission wasn’t required for every little detail. Clearly, he’s got a friend in Dr. Ron Cyr whose commentary included an equally alarming statement: “Unless a patient asks, it is not customary to describe the minutiae of surgical ritual.” Maybe so, but I think most people would agree that the pelvic examination of an anesthetized woman, conducted by multiple medical students for the sole purpose of education, does not fall within the category of “the minutiae of surgical ritual.”

Doctors of the old school of thought need to get with the program. Keeping women in the dark is unethical, and there are laws in place allowing patients to refuse any care or examination by strangers. Mary Anne Wyatt of MA, my collaborator on Misinformed Consent, made a good point about this. She said: “They shouldn’t be doing (or saying) anything to an anesthetized patient that they wouldn’t do or say if she were a conscious observer.”

Dr. Cyr says that he suspects that few women undergoing gynecologic surgery at a teaching hospital would object to being examined by medical students. Here’s one woman who thinks that Dr. Cyr might be in for a surprise if he ever decided to put his theory to the test by actually posing the question to his patients.