This was posted on another board that most of you guy don't go to I
felt that it was important to all of us.

August 12, 2003

WANTED — A HEALTHY DOSE OF HUMILITY AND RESPECT FOR PATIENTS' RIGHTS

By Lise Cloutier-Steele

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.

Lise Cloutier-Steele is a communications specialist and a professional
writer and editor, who has survived a traumatic experience with
hysterectomy. She is the author of Living and Learning with a Child
Who Stutters, and the recipient of a Canada 125 Award in recognition
of a significant contribution to the community and to Canada for her
volunteer efforts to help the parents of children who stutter. She is
also the author of MISINFORMED CONSENT- WOMEN'S STORIES ABOUT
UNNECESSARY HYSTERECTOMY, and she has recently appeared on Canada AM,
the Women's Television Network (now W), The Phil Donahue Show, The
Body and Health Show, and several other media to talk about this
important women's health topic.

http://www.redflagsweekly.com/cloutier_steele/2003_aug12.html

nada

Wow! This was incredible. I wish I could elaborate...but my neck and hands
are KILLING me. I thank you for sharing this. I printed it out to bring to
my doctor's office tomorrow in case he gets 'snippy' with me! LOL!

Nada

p.s. I'm familiar with that movie "The Doctor" with William Hurt.

bookbabe

I've got rectal cancer that was first diagnosed in Oct. 2000. By the
time I was diagnosed I'd had umpteen different fingers in my bottom,
never mind all the scopes.

So you can imagine my mood when I came in for a final scope before the
surgery to remove the tumour. My surgeon wanted to assess how low the
tumour was, since that detail would decide whether or not I'd need a
colostomy.

Before the procedure, my surgeon took me into his office and explained
that he had a medical student and a resident working with him, neither
of whom had worked with a scope. And the med. student had not
performed a digital rectal exam yet. The surgeon asked if these two
could assist in the procedure. He said he'd understand entirely if I
said no, and that I shouldn't feel pressured to say yes.

What the hell- what's a few more fingers? I said yes.

He then brought the resident and the med. student into his office.
Both of them shook my hand and thanked me for the privilege of being
allowed to learn more about rectal cancer with me.

I thought that was pretty nifty.

Michele

camille maxwell

Oh mygosh..That was something, when I first had problems the horror of being
seen naked on an operating table horrified and silly me thought I was being
vain..I was a private patient in a teaching hospital and I had medical
student after med student question and poke me probe me and view the nether
regions and many a rectal and viewing of cervix, not once was I asked but I
was told..Well now after more operatrations then I can count an more
admissions thru emergency then I can remember,I felt I was over the peek
from the registras geeks...Thanx for highlighting this I am more aware and
will be better prepared.....Camille

nada

That is pretty cool that you were treated so well. I'm glad to hear the
positives. I've had many negative experiences, but mostly when I was much
younger...with the exception of an assistant in my OB-BYN's office.

Nada

I remember being on my 47th hour a labor ready to push when I was told
I had a Bottom Breach they brought every medical student into the room
to see. At that point I just didn't give a damn I wanted that F.......
Baby out right now. Ended up with emergency C-Section. She one of the
most satisfying thing in my life, getting ready to turn 21. In her 4th
year at Cal Poly San Luis Obispo.
But I did think about sitting there wide awake with 10-12 people
looking where no one should be looking, after she was born even yelled
at the DR about it.

Cristy

<<<SNIP>>>

nwbluepenguin

I agree....it's nothing more than rape with a foreign object.

How can a profession that is suppose to be based on "ethics", condone this type
of behavior?

At least it is on the decline now. I don't think too many women would turn
down the opportunity for a med student to learn this procedure. Common sense
tells me this is not something to do without the patients knowledge. I guess
the medical profession (not you Hawki) has no common sense.

jon and mary miller

<snip the whole thing, because it's too hard for me to prioritize the
importance of the different points>

I read a study several years ago that discovered that what drives
malpractice suits isn't quality of care, but bedside manner. The
arrogant doctor who rides roughshod over the patient is the one who gets
sued even though he "did everything right" but the patient didn't get
better, the one who "is such a nice man" doesn't even if he really
botches the surgery, or makes a huge blunder in diagnosis.

Interestingly, "The Doctor" is based on a true story. The doctor in
real life (_A Taste of My Own Medicine_ by Ed Rosenbaum) had a good
bedside manner and was very good with his patients. He wrote the book
mostly because he discovered, from the other side, that even when
doctors try to do it right, they still make mistakes communicating,
because they've never been on the other side and no one's ever told them
what it's like to be on the other side.

Doctors don't know what it feels like when you wake up after an
endoscopy. They don't know what post-surgical pain feels like. They
don't know what to tell their patients. That was why the real doctor
wrote the book.

Jon Miller

nwbluepenguin

Jon, reminds me of when I was in "hard labor" with my first daughter. My
husband asked the doctor "how bad does it hurt to have a baby?" The doctors
reply "I don't know, I've never had one."

This doctor was an OB/GYN and had delivered lots of babies. I appreciated his
honesty back then and still do.