- Okay guys,
today I wanna talk about something
that's been in the news lately
that's got a lot of people
upset, understandably,
and that is unconsented
pelvic exams under anesthesia.
Let me talk about what this is.
Okay so when I was a medical student,
and I was rotating on
OBGYN, in order to train us,
obviously we would see
patients in the clinic
with an attending physician
or a resident to supervise us,
and so if we were learning
how to do pelvic exams
with a speculum or the bimanual exam,
where fingers are placed inside the vagina
and you're feeling the cervix
and the internal structures,
The ovaries and feeling for masses,
you do that with the
consent of the patient.
The patient is there, they're awake,
they know you're there
and they purportedly approve
that you're gonna do this
and learn from the exam.
But another thing happens,
and this actually I think happened to me,
although I'm trying to remember
if we actually consented
patients for this,
when patients go into
surgery in obstetrics,
the patient is put under
anesthesia, they're asleep.
Now, at this time, when they're asleep,
the surgeon oftentimes
will very much benefit
from doing a pelvic exam
when the patient is asleep.
There are reasons for this.
Number one, it's less
painful both physically
and psychologically when the
patient is under anesthesia.
So the structures are softer,
there's more relaxation,
you can actually feel better,
you have more time and
you're not as concerned
about causing discomfort
because the patient
is under anesthesia.
You often need to do that
in surgery to feel masses
in the vagina, around the cervix,
to be able to put a speculum in
and actually open it a little
bit more than you would
when the patient's awake so
you can get a better look
at the areas around the cervix
and decide what your surgical
approach is gonna be.
So by taking a very good look
in a way that you can't do
when the patient's awake,
you can make decisions in surgery
that will change the outcome.
Do I do an abdominal incision,
do we go through the vaginal incision,
these are major, important decisions.
But the second that happens is,
while the patient is under anesthesia,
a medical student, an intern, a resident,
can perform a pelvic
exam in order to learn.
So they can feel the structures,
they can do all the things
that the attending can do
and actually be guided as to
how this is gonna influence the surgery.
Now the obstetricians that I've
spoken to prior to this show
say this is an essential,
crucial part of training.
Medical students,
residents, house staff etc.,
in how they're gonna
do their pelvic exams.
Now, this is not just
one part of the exam.
You're doing quite a few things,
let me walk you through it
and then we're gonna talk about consent.
So one of the things you
do is a bimanual exam,
so fingers in the vaginal vault,
feeling the cervix and
then pushing on the abdomen
to feel the different structures,
the ovaries etc.,
looking for masses
different things like that.
We won't go into full detail.
The second thing you do
though as a bimanual exam
is something called a rectovaginal exam.
And this is very invasive.
So one finger in the rectum,
one finger in the vaginal vault
and you're feeling the space
between those two structures,
for masses, movement, etc.
There's a lot of things
you can do, inflammation.
And this again is a
very invasive procedure
and then the third piece of
that is the speculum exam
where a speculum is inserted and opened
and you're looking inside.
So all of that done under
anesthesia presumably assuming
the anesthesia's good, the
woman doesn't feel this.
But here's the rub,
if that woman isn't consented in advance
that this is gonna happen,
these people are doing an exam on a woman
who has not given her
permission to have the exam done
as an educational tool.
So as part of the surgery,
the surgeon as part of the consent,
has to do the pelvic exam in
order to do the surgery right.
But that doesn't mean that
medical students, interns, etc.,
can take turns doing this exam.
But that's exactly what can
happen in unconsented exams
for teaching purposes.
And when I was a student even though,
whether or not we did
consent I don't remember
because the resident and
the attending filled out
the consent, not the student.
But then they would say,
"Okay Zubin, come and do a pelvic exam now
and I want you to feel for this
and I want you to walk me through it.
Do the rectovaginal,
do the speculum exam."
Even that, with the patient unconscious,
to me felt like a violation
and of course you don't say no,
it's a hierarchy and you're listening
to the attending physician
and you're feeling,
and the attending physician's a woman
and that doesn't make any difference,
you feel deeply uncomfortable
doing this on someone
who's asleep,
who hasn't verbally given you
their permission to do this.
And it creates a kind of moral distress
that you then build a wall around and go,
"Well everybody's doing this,
this is just how we train."
So here's the thing,
now it's becoming public
that this is something
that can happen, unconsented,
under anesthesia pelvic exams.
And I think to most people and to me,
this is a violation.
This is absolutely unconscionable
and we cannot allow it to continue.
Simple as that.
If you're gonna do an
under anesthesia exam
for educational purposes,
that should be in the consent.
And the gynecologist that I spoke to said,
"To a one, that's exactly
what they put in the consent."
These are the people who would be involved
in that procedure,
do you consent to this?
You can say no.
Now what I would advocate is this,
if it's causing moral distress
to the medical students all right,
then something is wrong already.
That we could use an unconscious body,
somebody's body and violate them this way,
is a deep, deep, deep
foundational violation of trust.
It violates the patient's
bodily autonomy, their liberty,
and it violates the concept
of informed consent,
that you don't do things
to people without consent.
So here is the call to action.
First of all, share this video
because a lot of people don't
even know this is happening.
If you're somebody that's
planning to go under anesthesia
and by the way if you
think this is only women,
it's not,
so men can undergo rectal
exams, prostate exams,
genital exams under anesthesia.
So this can apply to men too.
If you're planning to go under anesthesia
for any sort of procedure,
you should verbally tell the
people taking your consent
that you do or do not
want this sort of exam.
You can write it in your
consent as a write in,
there's lots of things you can do
to make sure that your wishes are known.
All right?
The other thing we can do is
we can talk about legislation
and things like that,
honestly I don't think this
should have to be legislated,
this should be part of our
ethical code as physicians,
that we get informed consent
where we're gonna teach.
Now here's the thing,
I am not saying get rid of
pelvic exams under anesthesia.
For all the reasons I've just said,
they are essential not just to teaching,
but to the care of the
woman undergoing surgery.
They are essential.
So let's do it right, respectfully,
and in keeping with our
hippocratic oath to do no harm.
All right guys call to action,
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