I have chosen to write this blog entry after failed attempts to get the mainstream media in Calgary to follow up on Andre Picard's article on pelvic exams that are reportedly performed on women under anesthesia in spite of a lack of explicit consent.
In October of 2009, I had exploratory surgery during which several large growths of endometriosis were found on my uterosacral ligaments and, subsequently, removed through cauterization.
I first experienced the intense pain of endometriosis in September of 2007; it seized my body for a couple of weeks and then disappeared overnight. An ultrasound was done but nothing was found.
In October of 2008, the pain returned with fury. I was in and out of the E.R, had multiple pelvic exams, a CT scan and, still, nothing was found. I was sent home with morphine. I attended classes and wrote my final papers for the semester pressed with pain and foggy with narcotics. Most fortunately, the pain subsided mid-December and my health was returned to me for a period of time.
In June of 2009, I began to experience intense pain near my tail bone. Again, I was in and out of the E.R. Now that the pain was manifesting in my back, I was repeatedly sent to the minor emergency department with the assumption that I had a back problem in spite of the fact that I had a clear bone scan. Again, I was put on narcotics and left to wait for an MRI that was not scheduled until October. When I finally got in to see my OB/GYN, he was reluctant to perform surgery because my pain was not consistent with the "Carnett's Test." (Incidentally, the academic literature describes this test as a tool in diagnosis but little research has been done on the predictive value of the test.)
I told my OB/GYN that I would find another surgeon to perform the surgery if he did not. He agreed to the surgery, scowling at me as he popped into the reception area where I was filling out the necessary paper work.
After my surgery, my OB/GYN came into my recovery room and apologized for his skepticism; he noted that my endometriosis was too deep for him to feel in a manual exam before skulking out of the room.
Like many other women, I was angered when I read Andre Picard's article in the Globe and Mail which revealed that many women are given pelvic exams under anesthesia in spite of a lack of explicit consent. Picard reports on Dr. Wainberg's research in Calgary:
When Dr. Wainberg took a position as a resident at Foothills Hospital in Calgary, she decided to study the issue further. She and fellow researchers polled 102 women who were patients at the Calgary Pelvic Floor Disorders Clinic.
The results – reported in The Medical Post and in the Journal of Obstetrics and Gynecology – are as fascinating as they are troubling.
Dr. Wainberg and her team found that fewer than one in five women were aware that a student might do a pelvic exam in the operating room. At the same time, 72 per cent expected to be asked for consent before such an exam was done.
The patients – unlike medical educators – seem to be quite clear on the concept of informed consent.
What is particularly troubling is the medical professions quick defense of the current guidelines which state:
As pelvic examination under anesthesia is a component of most pelvic surgeries, consent for pelvic examination by medical trainees is contained within consent for a surgical procedure.
Rather than taking Wainberg's study as evidence that the current guidelines are not sufficient for the process of informed consent, medical professionals are providing knee-jerk defense of current practices. For instance, Dr. Wilson, head of Obstetrics and Gynecology at the University of Calgary, writes:
In Calgary, patients give written consent for medical students to be involved in their surgical care, including medically necessary examinations, and patients are specifically informed before surgery, by the surgeon, that they may be examined by a trainee. If a patient objects, their wishes are honoured.
A medical student can only undertake a pelvic exam if the exam is required as part of surgery and the student is part of the surgical team.
Dr. Sara Wainberg's paper discussed women's attitudes to pelvic floor examinations being undertaken by medical students, in relation to consent. The concern expressed by a number of scholars is whether implicit consent for pelvic-floor exam under anesthetic, by a trainee, as recommended by the Society of Obstetricians and Gynecologists of Canada guidelines, is sufficient.
Certainly, surveys of attitudes and beliefs can lack validity. For instance, there may be little correlation between one's beliefs about their abilities in mathematics and their performance on a math quiz.
But, here's the thing - attitudes are a pretty critical measure of the success of informed consent. If a bunch of women were not aware that they were agreeing to pelvic exams by medical students then they were not properly informed.
On the issue of informed consent, it is the person who is doing the consenting whose beliefs are paramount. Clearly, women do not realize that they are consenting to medical students performing pelvic exams. Indeed, in my case, I had upwards of ten pelvic exams in a year before arriving at exploratory surgery. As a layperson, I did not imagine a pelvic exam would be part of the surgery- had we not arrived at surgery because pelvic exams were not providing answers? Also, I am confused about the "medical necessary" component of this language. If my surgeon performs the medically necessary exam, aren't subsequent exams by students redundant?
My anger has less to do with the pelvic exam itself, but the notion of "implicit consent" and the reaction from some medical professionals, including dismissive remarks about women's "attitudes." Maybe, if my attitudes and beliefs were given more weight in the first place, my pain would have been taken more seriously and I would have received treatment sooner. My experience with endometriosis sure as hell reinforced my formerly shaky belief that: I am the expert on my own body.
Given the historical mistreatment of women by the medical profession and ongoing societal violence against women, one would hope that both the national association and local medical departments would choose to pay a little more attention to women's beliefs and attitudes, as well as our explicit demands for respect of our boundaries.
Let me conclude with some of the comments on Picard's original article that I found on an internet discussion board for medical students in Canada:
I've done bimanuals on patients during gyne surgery, but they are usually consented for an "exam under anesthesia" as part of their surgery. I've never seen them done unnecessarily, and they are almost always indicated prior to any gyne surgery. It's never a "parade of medical students" it's only those who are scrubbing to assist (so usually a resident and a med student. I do agree though that there should be more explicit consent, and women should be told that an exam will be done after they are anesthetized by the surgeon and assistants.
So, in the context of pre-operative and intra-operative evaulation, a vaginal exam is invasive, yet OPEN SURGERY isn't?
This guy is an a55hole.
as a few people have mentioned, the issue is not with the pelvic exam itself, but with the lack of consent.
i don;t know how many of you have been present when a woman is consenting for gyne surgery, but honestly, how often have you heard the surgeon mention that a pelvic exam is done while she's under anaesthetic? I've never heard anyone explicitly say this (let alone mention the fact that the exam will be done by the surgeon, 2 residents, and one or two medical students). Usually it's like "risk of bleeding, infection, perforation, converting to open, etc etc"
i've felt uncomfortable doing these in the past (though never declined to do one). i'm not going to be an obs/gyne, so knowing whether the uterus is ante or retroverted is not useful knowledge really. besides, we get to do pelvic exams on AWAKE, CONSENTING patients as part of our rotation anyway.
i agree the article promotes some fear-mongering, but it's not without it's merits. if it was my mother or girlfriend going in for surgery, i wouldn't want my classmates doing unnecessary pelvic exams.
Clearly, there are is a lot of confusion - whether the exam is less invasive than the surgery itself or whether doctors know that pelvic exams are routinely part of pelvic surgeries is absolutely irrelevant to the issue of informed consent.
Do women realize they are consenting to pelvic exams under anesthesia?
It appears that women do not realize that they are consenting to medical students performing pelvic exams and current guidelines and practices fall short of achieving informed consent from women undergoing medical procedures.
I strongly suggest that the Society of Obstetricians and Gynecologists of Canada revise their guidelines and educate students and doctors about this issue. Clearly, "implicit consent" is not amounting to informed consent. Moreover, it seems that a larger discussion is needed about respect for patients, appreciating women's expertise on their own bodies and recognizing patients' rights to set their own boundaries as ridiculous as they may seem to some students and doctors.