Should you be allowed to perform sensitive examinations when a patient is under general anaesthesia?
A 38 year old woman, G2P2, presented to the Gynaecology Outpatients Clinic at North Shore Hospital after having progressive abdominal pain over the past 6 months. She had noticed that the pain worsened during the time of her periods and that the bleeding would be heavier than usual. Over the recent few weeks she had felt an increasing pressure sensation in her lower abdomen. Her menarche was at 13 years old and her menstrual cycles were regular, averaging between 26-30 days per cycle. She had not experienced any inter-menstrual or post-coital bleeding. Her last menstrual period was 10 days prior to presentation. She has been pregnant twice, with both pregnancies carrying to term and without encountering any complications. She denied having any discomfort during sexual intercourse and her cervical smears were all up to date. She denied having any nausea, vomiting, change in bowel habit, or urinary symptoms. Her past medical history and family history was not of relevance.
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On physical examination there was a firm, irregular mass located in the suprapubic region of the abdomen comparable to the size of a cricket ball. A transabdominal ultrasound scan was performed and it revealed a hypoechoic mass measuring 12 cm x 14 cm. There was no free fluid noted on the scan. It was concluded that the diagnosis was a fibroid.
She was scheduled to have a surgical removal of the fibroid via myomectomy in the operating theatre, which was where I first encountered this patient. I had introduced myself to the patient prior to surgery and gained consent to observe the surgery. However after the patient had gone under general anaesthesia, the Gynaecology surgeon had asked me to perform a pelvic examination and report my findings. At first I was sceptical about doing this, but I proceeded to do so and reported my findings to the surgeon.
Considering the ethical dimension
The main ethical issue that came to my attention was that I had not gained consent from the patient to perform such a sensitive examination such as a pelvic examination. When the Gynaecology surgeon had asked me to perform the pelvic examination I questioned whether it was okay to do so, and the response I had received was “yeah you are part of the team”. I had not specifically questioned whether I needed to gain consent from the patient first, as I did not feel it was in my place to speak up to the surgeon and question them. This in itself raises another ethical issue regarding hierarchy within a medical team, which I will not go into detail. Informed consent is a relatively new concept in the history of medicine however it has now become a vital part of modern medical practice. According to an article on Informed Consent by W.Grossman et al. (July 2019), it states that “informed consent must include 3 major elements: 1) disclosure of information, 2) competency of the patient to make a decision, and 3) voluntary nature of the decision” . With the patient being under general anaesthesia, none of these elements would have been met prior to the examination taking place.
Most of the time, examinations are performed in an outpatient clinic setting where a patient is awake and has the capacity to either give consent or decline a medical student performing a pelvic examination . However in an operating theatre, it may not have been fully clear that a medical student would be performing a pelvic examination while they are under general anaesthesia, and therefore leading to a discrepancy as to whether consent had been truly given or not. In this situation the potential for harm can definitely arise especially if the patient were to find out this examination took place without their knowledge. Not only could this lead to a breach in trust between the patient and the medical team, but also the medical student feeling discouraged about performing a pelvic examination on a patient ever again, and in the worst instance the possibility of facing a penalty for medical malpractice. The purpose of informed consent can be thought of falling under three headings; “Legal: to protect patients’ autonomous decision-making, and support patient-defined goals; Ethical: to protect from assault, and prevent unwanted procedures; Administrative compliance: to document that the parties were involved in the informed consent process, and provide efficient safeguards to ensure nominal fulfilment of ethical and legal requirements” .
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Every healthcare professional should follow the medical code of ethics and one of the principles states that we must do no harm. To do no harm means to refrain from acting with malice towards patients . In the case above, the surgeon may have not purposefully intended to cause harm on the patient, but instead caused harm to the patient indirectly by exposing the patient to an unnecessary procedure, thereby breaching the patient’s right to non-maleficence. Regardless of how valuable it would be for teaching purposes, I believe that the surgeon should not have asked a medical student to perform a pelvic examination in a theatre setting unless the student has personally gained consent from the patient in either verbal or written form. Even if it was discussed during the consenting procedure that the team comprised of nurses, doctors and students that may all be involved in the patient’s care, the patient may not be fully aware that this involvement would involve a sensitive exam. Every patient should have the right to make a choice about things that happen to their own body without external influence.
Demonstrating my reflection on the case
I decided to choose this topic because I found it difficult to speak up due to the values that shaped me as I was raised. Throughout my upbringing I have been taught to never question an authoritative figure especially if it is a doctor. These values were shaped from my Nepalese background and in our culture we hold the utmost respect and trust in doctors as we tend to view them as a “God”. It would be considered disrespectful to question a doctor’s judgment in Nepal therefore nobody raises a voice. Objectively speaking, when one has spent many years as a surgeon diagnosing problems and fixing them, it is easy to forget to treat the patient rather than the problem. From an observer standpoint throughout my clinical years, I have seen many surgeons failing to consider a patient’s perspective with the decisions that they make. It occurred to me that as an ‘observer’, i.e. medical student, it is quite easy to see things from a different point of view and consider ethical dimensions without a biased opinion.
What I learnt from this case is that not all medical decisions are right and we should not be afraid to question them regardless of your position on a medical team. More often than not it is insecurity that prevents us from speaking up, and in this scenario it definitely was my own lack of courage and fear of embarrassment that made me reluctant to speak up. If I were to come across a similar situation like this in the future I would not hesitate to speak up and try to raise the concern without sounding judgmental or provoking in any way. The way I could build up the courage to do so would be to try imagine how I would feel if the patient was a family member of mine such as my mother or sister. I think it is important for us to not be afraid to raise concerns because there will come a time in our lives where we must step out of our comfort zone. Everybody has a voice so we must not be afraid to use it.
- Gossman, W., Thornton, I., & Hipskind, J. E. (2019). Informed Consent.
- Hammoud, M. M., Spector-Bagdady, K., O'Reilly, M., Major, C., & Baecher-Lind, L. (2019). Consent for the Pelvic Examination Under Anesthesia by Medical Students: Recommendations by the Association of Professors of Gynecology and Obstetrics. Obstetrics & Gynecology, 134(6), 1303-1307.
- Hall, D. E., Prochazka, A. V., & Fink, A. S. (2012). Informed consent for clinical treatment. Cmaj, 184(5), 533-540.
- Gillon, R. (1994). Medical ethics: four principles plus attention to scope. Bmj, 309(6948), 184.
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