Inappropriate emotional in the Doctor’s Office

How an excellent intentions revolve into bad actions

posted August 9, 2012




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I feel a woman’s uterus without her permission. How this happened, and why I thought I had done the right thing in ~ the time, tells united state something important around medical education and shows us why doctor/patient interactions frequently play out favor conversations between earthlings and also aliens.

To recognize my inappropriate actions, you require to know something about the physical exams the we doctors conduct on our patients. Much more specifically, about the pelvic exams we execute to assess whether a woman’s uterus or ovaries are possibly diseased.


Almost nobody enters medical school v any an abilities at examining patients’ bodies. Consequently, the very first time clinical students listen to your patients’ hearts, they space lucky to identify the proverbial “lub” indigenous the “dub”—what in technical terms we contact the S1 and also S2 love sounds. It takes dozens that listenings before medical students are able to identify 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 come the challenges of performing professional pelvic examinations. For starters, as soon as a medical student listens come a patient’s heart v a stethoscope, the worst outcome because that the patience is the emotion of cold plastic on their chest. One inexpert pelvic examination, on the various other hand, can be painful because that patients. Add to the the sheer uncomfortableness of an even expertly performed pelvic exam—this is after all a very private body part being palpated in a path that even under skilled hands is usually embarrassing and unpleasant—and the an extremely act of practicing a pelvic examination feels favor a significant intrusion. Any woman willing to permit a clinical student study her (before the an ext experienced medical professionals inevitably repeat the examination) is law the medical profession a big favor.


Pelvic examinations different from heart exams in another important way: lock are lot more an overwhelming for clinical students to glean details from. An experienced doctor conducting a pelvic examination can discern whether a woman’s uterus is mal-rotated; whether either of her ovaries is enlarged; and also whether palpation that the uterus causes a woman to endure disproportionate discomfort, a reaction that can signal underlying pathology. Yet together the female obstetrician who supervised me throughout medical school put it come me: “The an initial dozen pelvic examinations friend perform, friend won’t feel a uterus, and you certainly won’t feel any ovaries; friend will simply feel warm.”


Indeed, the pelvic examination have the right to be an acutely uncomfortable portion of the medical encounter because that students come learn. Us feel nervous research women’s exclusive parts; us feel embarrassed at failing come glean any type of information from the test after patients have actually been kind sufficient to let us exercise on them.


But we understand that we have to overcome our nerves and practice. I absolutely knew the my must practice as soon as I walked right into the operation room the day, in 1987, gowned and also gloved and prepared to help the surgeon in any method possible, help that given my nearly complete ignorance the gynecologic surgery mostly would amount come holding a retractor throughout the procedure. (A retractor is a clinical instrument offered to hold back, say, wrinkle of skin and also muscle native the underlying tissues being surgically treated.)


“Student, come over below right now,” the surgeon said. “We should start the operation, yet you should examine the patient first.”

I necessary to study her? i couldn’t see how that would assist anyone. I had actually never met the patient before, but instead had actually simply been told come head over to operation suite number three, or every little thing number suite the was, to help in the operation. I hesitated, which just prompted an ext urgent beckonings from the surgeon:


“Come over and feel her uterus,” she called me. “She has a big uterine mass. You must know how to acknowledge this kind of fixed on a pelvic exam.”

My man was apparent to see, in spite of the operation mask covering the lower fifty percent of my face.

“Don’t worry,” the surgeon continued. “She’s anesthetized and also won’t feel a thing. Plus, she muscles are entirely relaxed from the anesthetics, so friend will have actually a much simpler time emotion the anatomy.”


I placed two finger from my best hand right into her vagina, pressed gently on her abdomen through my left, she uterus currently squeezed between my two hands. Yep. Identify mass. My physics examination skills were currently inching in the direction of expertise. My surgical supervisor had actually helped me develop as a physician.

But of course, she’d likewise shaped my moral development. I had actually examined the woman, ~ all, without her permission. How might the surgeon and I have thought the it was acceptable to execute this? I can only speak for myself. To start with, i was frantically obsessed with learning my brand-new trade. In addition, I wanted to impress the surgeon and get a great grade ~ above the rotation. So once I stood there in the O.R. That day, presumably dealing with a ethical dilemma, i barely provided the instance a 2nd thought.


The result of that was that I began thinking that this sort of action was ok. The surgeon, after all, was a wonderful person, cursed to clinical education and patient care. And I knew the I had actually nothing but good intentions in evaluating this patient. There to be nothing prurient in mine behavior. I simply wanted to end up being a much better clinician.


But I’m sure if we had actually woken up the woman and also told she what happened, she would have actually been horrified. The females I have surveyed on this topic to speak that, when they’d be ready to provide permission for medical students to exercise pelvic examinations ~ above them, they would certainly feel violated if such practice arisen without your permission.


Moral attitudes are frequently a function much more of our experience than of our training. As soon as some colleagues and I surveyed medical students and asked lock how crucial it was to asking permission prior to conducting a pelvic test on one anesthetized woman, brand brand-new medical students virtually universally declared that permission was crucial but by the time the college student finished your OB/GYN rotations three years later, castle didn’t check out permission together being necessary anymore (see record here). Regardless of the lectures they’d received about “informed consent” during the first two years of clinical school, 6 weeks of an OB/GYN rotation was enough to change their ethical attitudes.


How deserve to an ethics lecture contend with a palpable uterine mass?


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Peter Ubel, M.D., is a physician, behavioral scientist, and also professor that Business and Public plan at duke University. He is the author of Critical Decisions and Free market Madness.