Exam Under Anesthesia

Ah, ethics.

The OB rotation includes the requirement that medical students participate in 'exams under anesthesia', which are completed in almost all surgical specialties. Orthopedics is another rotation where you can learn a lot from these situations.

In OB, though, I'm not so sure it's so straightforward. Technically, we're performing an extra, and theoretically unnecessary pelvic exam. That's a bit different than an extra knee exam. And this with the patient unresponsive.

ACOG, the governing body of OB, says that exams under anesthesia are allowable with specific consent. But, like all things that involve consent, they are put on the form but not typically discussed in length. How many people would consent if you said, 'is it OK if the med student performs and extra exam on you while you're out?' Probably, some would, or even most, since many are open to helping education.

I completed these because, even though it felt weird, I would've had to cause a big stink to not do it. But ethically, we've been taught that we should avoid even the appearance of impropriety. Does this count? Is this something that is emotionally important enough to specifically discuss in consent? Or am I just uncomfortable? Probably I'm just uncomfortable.

There are a lot of times when we inconvenience patients for educational purposes. I think the way to deal with that is to recognize the debt you owe to all patients for those that helped you learn, and repay that debt with quality care.

But those exams still make me uncomfortable.


"Who are we to play God?"

I'm down to a post a month. Sorry. Things should pick up soon. Currently I'm taking a break from multiple choice questions contrasting various treatments for a rectocele, which, by the way, is caused by a loosening of the levator ani fascia, and results in the rectum encroaching into the vagina.

I have my doubts about my future career proceeding in uro-gynecology. Not that there's anything wrong with fixing such problems. Anyway.

OB has been hard to write about. But I figured it out reading an article in the NY Times about gender selection. The director of a prominent fertility center in the above article perhaps questioned a doctor's right to play God, but, interestingly enough, he was in support of allowing a patient to choose the gender of their child. He essentially said, if the patient wants to have a girl, who are we to play God and prevent them from making that choice? Clever, to turn the argument on it's head that way.

Aside from chuckling at the inversion of logic evident in such a turn of phrase, it got me thinking that doctors constantly play God, so to speak. Fertility is an obvious example. But every operation or intervention is essentially an attempt to monkey with the divine design of nature. Are we not playing god when we insert three or four instruments into someone's belly to extract a hemorrhagic ovarian cyst? Certainly we are not trusting to nature to sort things out. Certainly there is some element of intervention there.

And we would not have it any other way. The hubris necessary to even think of taking a person caught in a car accident, opening their stomach, and ripping out their bleeding spleen in a matter of minutes is a bit mind-boggling. Thank goodness we do it. If we weren't a bit hubristic we'd be paralyzed by indecision.

But what's the real difference between that and fertility other than speed? The person in the car accident may have made any number of questionable choices, just as some say fertility seekers and the doctors who treat them are on shaky moral ground. The trauma victim may have been a 21-yo, intoxicated, unbelted, ejected driver found on the scene of a multi-car accident unresponsive. In the absence of any recorded spontaneous resuscitation and splenic rupture repair in the field, I'd have to say, we're 'playing God' and altering the natural consequences of his choices.

So to say that fertility docs are somehow monkeying with God's natural order more than doctors in general is a bit false.

I don't actually support choosing a gender, and I think most couples who want the most expensive fertility interventions should actually adopt, since they often aren't using their own genetic material anyway. But that's my personal opinion, not my professional one. Let's face it, we're playing God all the time. Perhaps the real hubris comes when a doctor says, 'you may play God', and, faced with someone else, 'you may not'. Perhaps the very argument should be discarded altogether.

This one isn't sorted out yet, more later. Back to Burch slings and cystoceles.