Wanted. Medical ethics opinions please...Re: Medical trainees/interns

[PotatoChip]

performing pelvic exams without the consent of the patient.

Yup, this actually happened to my 18 year old niece on her first ever gynecological appointment. My sister is livid. I can't say that I blame her, but would love to know what you guys think.

Ok here is what happened:

First let me begin by saying that my niece is what I'd call "a young 18". She's very bright, does well in school, but is a bit shy and on the naive side. Which is why it's a very good thing that she and my sister are so close. My niece tells my sister everything, including the fact that she feels 'ready' to go a little farther in her relationship with a young man (same age) that she's been dating for over 6 months.

They of course, had a long talk about it, the pros and the cons, ect. but in the end, my sister agreed to take her to a gynecologist for contraception as well as a routine type exam. My niece of course, was a bit nervous and resisted seeing my sister's regular OB/GYN. She insisted upon a female doctor whose practice is some distance away.

My sister didn't go in for the actual exam because my niece wanted it that way. On the way home, prescription for 'the pill' in hand, my niece seemed unusually quiet. Finally my niece tearfully opened up to my sister about how 'a man' had examined her in addition to the female doctor. Apparently this guy was some sort of medical student or trainee.

Ok, I realize that medical students need to learn, but what makes this incident egregious imo, is that 1) Not only was my niece not asked if it'd be ok, 2) The female doctor didn't even bother to introduce this guy to my niece as a trainee (or whatever). We still don't know exactly who this guy was to be honest. My niece said that he had no nametag on anything to indicate who he was and what level of training he had had. Plus she had specifically wanted only a woman to examine her.

Apparently during the pelvic exam, the female doctor had him sitting right next to her on a stool, explaining the steps, and then handed the speculum to him so that he could "try". My niece said it hurt when he collected the pap sample. The doctor also allowed this random guy to do an internal exam by hand.

You may be wondering why my niece didn't speak up in protest. But please keep in mind that this was her first time, she has a tendency to defer to adults in authority, was very nervous, and just plain didn't know how to handle the situation. All of this happened yesterday, and the office was closed for the weekend by the time my sister learned of what had happened. But she is seriously considering calling the doctor's office on Monday to complain.

I've been doing some googling about this. Most of the cases cited where about trainees who were asked to give pelvic exams to anesthetized patients in teaching hospitals. Patients who had not consented. Apparently this sort of thing happens shockingly often. Oh, and surprise, surprise-- It's much more common a practice for poor women and minorities.Some of these teaching hospitals have tried to justify this practice by saying a woman "implies consent" by the very fact that she agreed to medical care in a teaching hospital.

In the case of my niece however, this was *not* a teaching hospital but a private practice. I did find some useful info in one PDF file. From what I can tell, nothing illegal had occurred. However, in that file, the info went into great detail about the ethics of this practice- (or lack thereof) including cases like my niece's when the patient is conscious. I'd post the link- but I'm having trouble with it.

Sorry this is so long, but if you've read this far, is my sister and niece right to be upset? What do you think? My poor niece says she felt 'violated'.

[pnwmom]

1. Of course your niece's feelings were justified. It's never easy to have the first exam

and this girl is still a virgin.

I've had trainees (nurses and doctors) involved in my care, and they've always been introduced to me and I've been given the chance to consent. I thought that was required. I'm so sorry your niece had to go through that.

She certainly shouldn't have had a newbie poking around inside her during her first pelvic and without her permission.

[PotatoChip]

5. Yes. I feel very sorry for her.

I hope she doesn't feel traumatized for very long. Poor kid.

[cbayer]

2. Your sister should call and talk to the doc.

Trainees are to be introduced and permission obtained before doing anything. If it happened the way your niece reports, it's a pretty serious violation of the ethical standards put in place by both the AMA and the specialty organization.

[PotatoChip]

4. Ah, the AMA. I hadn't thought to

check out their info. Thanks. If this is a true violation, perhaps the doctor needs to be reported?

[cbayer]

7. I would talk to her first and hear what she has to say.

Not all doctors are members of the AMA, but their ethical guidelines are widely accepted as SOP.

If you do decide to report, you would report to the licensing board in the state. They would generally investigate and, if there were a number of complaints, they might act.

It's a difficult situation. I remember my first OB-GYN visit, and I was really, really nervous. Even if I had been asked if a trainee would examine me, I would have probably said yes just because of my own fear. But not being asked is just not right.

[PotatoChip]

8. Good advice. Thanks

I think it's good in a way that my sister has the entire weekend to consider what, if anything, she should do.

[cbayer]

9. Just one last thing - I wouldn't let it go.

At the very least, it is an opportunity to give the doc some feedback.

Doctors these days are often stressed beyond words, and female OB-GYN's are in extremely high demand in many areas. She may have just gotten lax about correct protocol and a reminder might go a long way.

[rox63]

3. Patients should always be asked if they are ok with a student or trainee

examining or treating them. Especially in a private practice situation, where they are expecting to be treated by a particular doctor.

[PotatoChip]

6. It seems so callous

the way this doctor went about this. If not illegal (it may be) but even if not illegal, it certainly seems very unethical. Grrr!

[NV Whino]

10. Unconscionable

1. She (and the accompanying adult—you) should have been informed there would be another person (male) involved in the exam.

2. She should have had the right to refuse.

3. And whatever else, he should have had a name tag and been introduced.

I would call the office on Monday and express your concerns. Based on the outcome of that conversation, I might report her to the ethics board.

An additional note: male doctors are required to have a nurse (presumably female) in the room during a pelvic exam.

[kdmorris]

11. I would definitely call and complain

My last pap was with a new OB/GYN, a woman, who had a male intern. He had a uniform on that identified his school, as well as a nametag that stated his name and position "Medical Student". She came in first and asked if it would be OK for him to take my history, to which I consented verbally.

He came in and was probably more nervous than I was, trying very hard to remember all the questions to ask. When she came in, she confirmed that he had asked the right questions, did my exam and pap after asking it was OK for him to stay (to which I consented) and then asked it it would also be OK for him to perform an exam. She stayed there the whole time and while it was quite weird for her to be teaching him while he was doing the exam (Do you feel the cervix there?, etc), it was OK.

The differences - a) I was asked to consent to EVERY step. She didn't just ask me once and assume I'd be fine with the rest of it. b) I am not a virgin - have given birth to three children.

I would definitely have your sister get to the bottom of it. Right to be upset - um, yeah. I have an 20 year old daughter who sounds similar to your niece - kind of shy and naive. If her first pelvic exam had gone that way, I would be livid and my helicopter Mom would come out with a vengeance.

[cbayer]

13. The process you describe is exactly the way it is supposed to happen.

[LASlibinSC]

12. That was wrong

First time patient.First pelvic exam, no consent, no introduction all reasons not to do that. Please call and speak with this Dr. In nursing school my instructor spoke with patients in a teaching hospital before I even got there to get their consent. Then I went in introduced myself and asked again. What happened to your niece is just wrong.

[Warpy]

14. Yes, she's got a right to be upset. I'm furious and I don't even know her.

There were occasional patients with interesting things that new grads needed to know about. I always asked their permission to have someone else listen to their heart and lungs or check out a neurological phenomenon and I always respected their answers either way. Informing them was key, as was allowing them to turn it down. I never failed to introduce the new person.

I'd send a letter about this to the medical board. I'd also check to see if there are nurse practitioners in the area in gynecology practice. Doing this to anyone is bad. Doing it to a green kid who is already terrified is horrible.

[hedgehog]

15. What happened to your niece was wrong - but, on the flip side -

my doctor always has trainees working with him, and I have consented to have them do the pelvic as well as other exams. I figure if I want the benefit of well trained medical people, I should do my part to help train them!