6.21.2007

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.

17 comments:

Teresa said...

I've never heard a doctor or medical student comment on this: is it right to allow a patient to be under anesthesia LONGER just so you can do a practice exam? I can't believe THAT is ethical.

Isn't it anesthesia dangerous, and the longer, the more dangerous it is? Please don't answer with some "it's only a little more dangerous" spiel. Why should the patient take on additional risk for your education?

tyro said...

Teresa,

I agree with you that longer time under anesthesia is not a good idea. In practice, the time is usually less than a minute for a bimanual exam, so it's hard to quantify the risk. I was more worried about the ethical dilemma of submitting someone to an extra exam they might find objectionable if awake.

Patients shouldn't take on extra risk for our education in theory. There are some institutions that designate cases 'not a teaching case'--that is, the risk is so grave that education goes by the wayside. In practice, though, everyone has to do procedures a first time, and there is more risk for the patient in those instances.

You raise a good point. This is why lots of patients choose to go to private hospitals rather than teaching hospitals. The counter argument is that the overall level of expertise in the supervising physician is greater at teaching hospitals--that's why they got a job at a teaching hospital. I'm not sure if there are good studies on this or not. It's an issue, though, for sure.

Teresa said...

In practice, though, everyone has to do procedures a first time, and there is more risk for the patient in those instances.

An excellent point. OK, I get that doctors have to learn each procedure on someone. But still, exams that don't need to be done under anesthesia could be done pre-op.

The pelvic exam thing still bothers me a bit, probably because no woman I know feels less than completely vulnerable having them. And then to have one unconscious, well, the mind balks at that. Too many weirdos out there. There was one guy who would stimulate anesthesized patients to orgasm with forceps, another who had carved his initials on a few patients in intimate places, and so on. It's hard to bust freaks like these, so they stay in practice beyond the first few "victims."

But then, to allow general anesthesia is to make yourself completely vulnerable to a bunch of people no matter what. In general I find it disconcerting that I cannot establish a trust relationship with all of the people who would be involved in surgery, so the whole notion creeps me out.

Sid Schwab has written about his feelings on seeing patients unconscious, the trust that they placed in him. He gets it.

Anonymous said...

Glad I didn't give up on Google after hours of searching what exam under anesthesia actually means. Finding this intern's comment on EUA quite enlightening

I had a mastectomy and the op report said 1] left total mastectomy 2] exam under anesthesia and closure by Dr. XX

OK I read it to mean that the Dr. XX [plastic surgeon] examined the breast prior to closure [because op report said he abandoned the implant due to muscle damage]

Now I ask you, slipping in the EUA in that manner without my consent is more than deceitful. This means that INTERNS were examining me during breast surgery!

How ugly can the medical community get??? What animals!
I have more respect for the Mafia!!

Needless to say I am thankful for this intern's thoughtful discomfort - but doing anything to a patient without consent in my book is cause for a dr. to lose his license.

I will do what I can to make that happen.

Anonymous said...

Good luck with your mission to revoke that doc's liscence...

Unfortunately we don't live in prefect society where everyone can do a prefect exam just by reading about it and without any practice. The attending Dr. you are going after knows what he knows today because he did practice exams on women during his training.

Prehaps you should take a second to thank your mother for helping train him/her.

Teresa said...

but doing anything to a patient without consent in my book is cause for a dr. to lose his license.

Well, no, I don't think so. There are lots of things a doctor might need to do without your permission. By seeking care from a doctor, you've sort of granted a lot of permission, anyway, especially for a surgical procedure.

I will do what I can to make that happen.

What a gigantic waste of time and energy. I hear your anger, and I can appreciate why you would be so upset. I would be, too. But doctors don't lose their licenses for following standard procedures.

Your real target ought to be the hospital procedures. If you target the doctors, you are just getting revenge. People who are out only for revenge are some of the most detrimental-to-society people around. Not to mention, you need to get on with your life. Life is way too short to right every wrong, and if you have been wronged, you need to get over it. (I don't fully follow your logic. There must be more to the story than what you report, because nothing you say indicates that interns were doing EUAs other than your assertion that they were.)


Unfortunately we don't live in prefect society where everyone can do a prefect exam just by reading about it and without any practice.

I can't stand people who twist arguments like this. No one in this thread has argued that doctors don't need to practice exams. If I had a gynecological exam and my doctor asked if a student/intern could observe or practice on me, chances are I might say yes. The WHOLE argument is whether an exam should be done without the patient's permission or not. I would be deeply offended to have an exam that was strictly for education done without permission under anesthesia.

In any event, there are plenty of people willing to consent to such exams, so why even do them without permission? There's no need for this questionable practice.

I do hope you are not in the medical profession. < further comment left unsaid, but I'm sure thinking it about you >

tyro said...

Interesting that this post has raised so many issues. I think the power issue is bigger than the actual medical harm suggested by increased time under anesthesia and so on.

Exam under anesthesia in the op note can simply mean that the body part to be operated on was examined when the patient was out. This is often done in orthopedic situations as the resting muscle tone makes an injured knee or hip very difficult to examine when the patient is awake. It doesn't always mean a pelvic exam.

Saying that a doctor should lose his or her license is really harsh. Every patient 'consented' to the exam anyway; the question is whether or not it was well explained to them. You're suggesting that your doctor should lose their livelihood.

After having started residency, I don't have new insight to add to this, but I am always clear to state who I am and what my role will be--on OB now, but in labor and delivery, not in the OR. Almost everyone is OK with me around, and those who aren't say so, and we don't interact with them unless they are in an emergency situation.

I think this can be cleared up by trying to communicate more clearly.

Anonymous said...

"I hear your anger, and I can appreciate why you would be so upset. I would be, too. But doctors don't lose their licenses for following standard procedures."

You don't really believe that a pelvic exam is standard during a mastectomy?

After finding the post on this thread about exams under anesthesia - I reviewed my op report - which used these very words.
I did a lot of research on this very subject - Try Googling "exam under anesthesia" I have not found one link that did not refer to pelvic exam. It's calle EUA-

Yes there is much more to my experience than the EUA statement-

While under surgery - my surgeon clandestinely turned me over to another surgeon who I did not know who did unnecessary extended tests and surgery to satisfy his part as a principal investigator in a clinical trial. All while I was under anesthesia from mid afternoon until the next morning. [I do not say this lightly - I have supportive evidence]

He removed the major muscle and complete lymphnode system.
Although I questioned my deformity - I would never have known because --I was told the muscle had atrophied from prior irradiation - so the implant was abandoned. I didn't argue - and decided to live with it.

Later learned that the muscle and complete node systen had been removed. The extended surgery was not consented to nor included in the operative or path/report- The trial guide states that the test results and tissues went to the clinical study lab. Pretty slick~

All my life I trusted drs. and this time was no different. I actually was sick to my stomach when I finally discovered this reprehensible betrayal ~

If this could be done, in the name of research, the EUA for interns is pretty obvious. And you bet - anger or not - it is justice for the right party to be held accountable in order to protect other women.

My advice to patients going into major surgery - is to make a "conditional consent" that ALL attending medical personnel be identified prior to surgery and filmed during the whole procedure and request a copy.

Sorry if I come across harsh in any way- but I don't put all drs. in this box - However, you can understand that people should know about these backroom type of tactics.

Research hospitals that double as primary care hospitals should be carefully audited-

Teresa said...

You don't really believe that a pelvic exam is standard during a mastectomy?

Don't put words in my mouth. I never said anything that could even remotely be construed by rational thinkers to mean that I believe that.


Try Googling "exam under anesthesia" I have not found one link that did not refer to pelvic exam. It's calle EUA-

Good grief. That is some of the most stupid "research" I have ever seen. Your ability, or lack there of, to draw proper inferences is unusual.

As far as I can tell, you were not examined by interns, nor did you receive a pelvic exam. You previously wrote,

I had a mastectomy and the op report said 1] left total mastectomy 2] exam under anesthesia and closure by Dr. XX

OK I read it to mean that the Dr. XX [plastic surgeon] examined the breast prior to closure


You read that to mean that the plactic surgeon, not interns, examined your BREAST prior to closure. Nothing was said about a pelvic. Yet because everything you can find on Google refers to pelvic exams when the phrase "exam under anesthesia" is used you somehow believe that that's what happened to you? That is irrational.

Besides which, IT'S NOT EVEN TRUE! I just googled "exam under anesthesia". The first hit was an eye EUA. The second was a youtube video of a breast EUA needed for surgery. The third hit was a rectal EUA. The fourth hit was this post. The fifth hit was a pay site, but returned at least this: "For determining the extent of calf tightness, exam under anesthesia has even..." indicating to me that the calf was the part being examined under anesthesia. The next was a form for consenting to an eye EUA. The next was a post inquiring about billing codes for an eye EUA. The next was a complete physical EUA. On a gorilla. The last one on the first page was a shoulder EUA. I found 9 links on the first page that did not refer to pelvic exams.

Sheesh.

All while I was under anesthesia from mid afternoon until the next morning. [I do not say this lightly - I have supportive evidence]

I'd like to see the supportive "evidence." This statement is not even credible, not with the previous irrational statements you've made to us, and not even on its face. Mid-afternoon is what to you--3 or 4 PM? Morning is what, 5 or 6 AM? You are saying that breast surgery lasted at least 12 hours? I don't believe you.

I would like to offer you some sympathy, but your statements are so incredible that it's hard to know what you have really suffered, if anything. Removing muscle tissue during a mastectomy can be very disfiguring, and I feel very, very sorry for women who have to have such extensive surgery. I am unclear whether or not that includes you.

You come across as incredibly irrational. I don't think what I say or what any doctor says will change your mind. Fortunately, I think most lawyers will find you not to be a very credible witness and will hesitate to take your case. If some wrong has been committed against you, (and again I point out that I cannot tell that is has based on what you write here), then that would be a terrible shame.

You would be much better off to take an anger management course. Your lack of logic skills are going to make it hard for you to really get to the truth.

All of us are capable of great self-delusion, including me. But you are a lot more dedicated to encouraging that self-delusion than almost everyone I know, and this can't make your life very easy. I see self-delusion as an obstacle to my goals in life, so I look for places where I'm deceiving myself and try to uncover the real truth, even if I don't like it. I recommend you give that a try.

Teresa said...

Every patient 'consented' to the exam anyway; the question is whether or not it was well explained to them.

That's the $64,000 question. My own view is that patients need to be clearly told, and given the option to decline.

Don't you observe and do pelvic exams on awake patients as part of your training? Why is the EUA without permission so important for pelvic exams?

Anonymous said...

YOU sure come out with your dukes up when you decide that you need to control a subject.

You don't get it that my FIRST Google search [the day I first posted here] was "exam under anesthesia"
The FIRST site that came up was THIS ONE!
Maybe you don't know this but on any given day - a Google search algorithm can change and bring up entirely random results.
So before you shoot from the lip - know of what YOU speak.

This is some of TODAY'S search a little while ago
http://www.google.com/search?hl=en&q=INTERNS+PRACTICE+EXAM+UNDER+ANESTHESIA+

http://www.obgyn.utoronto.ca/undergrad/Policies/Pelvic-Exam-Policy.htm

http://www3.interscience.wiley.com/journal/120786591/abstract?CRETRY=1&SRETRY=0
Unauthorized Practice:Teaching Pelvic Examination on WomenUnder Anesthesia

http://www.amwa-doc.org/index.cfm?objectid=E60C68BA-D567-0B25-

http://www.washingtonpost.com/ac2/wp-dyn?pagename=article&contentId=A36990-2003May9

Gynecological exams are changing as new students begin to question old practices. Medical students often perform pelvic exams when the patient is under anesthesia, not only without consent, but without informing them.
And the beat goes on..........


I find it interesting that your viewpoint is so rosy about the medical ethics in this country- that you refuse to believe someone who has no ulterior motive in posting the truth.

What is of concern - is that it is people like you - that refuse to accept that the medical community has and continues to practice on the vulnerable population for their own financial gain in the name of research.

Read up on Tuskagee - read the Belmont Report - read the federal regulations - See the Constant Gardner - See Mrs. Evers' Boys

How do you think these interns are learning? How do you think the research trials get the amount of subjects required? Trials are cancelled if they don't meet their quota. In order to publish their results to promote the drug, device or procedure they HAVE to meet the quota on subjects or the trial is cancelled.

In fact, OUR fed government funds many trials [like this one done on me]

Along comes a subject that is on state medical coverage.... and is told he needs a certain procedure....

Believe me, these subjects are UNAWARE that they are being subjected to practice for teaching students AND clinical trial procedures while under anesthesia for another surgery.

As for my comment about switching drs. for the clinical trial procedure you are strangely silent.

It's not much of a leap to think that if they were that EVIL --that they were above having interns brought in for an EUA class? [which of course I am not focusing on at all- because I cannot prove it]

I am not stupid enough to provide you with my supportive evidence - but I have 3 witnesses that will testify that surgery had not been done yet at 5:30 pm
I was admitted at 11 am and the last thing I remember it may have been 3pm
I was not out of the complete effects of anesthesia until 10 am the next morning. The time of the surgery will now be a legal issue in the future -

When the dr. came in - I was told there was NO cancer. Somehow she forgot to order a rediagnosis of the biopsy tissues. So HOW DARE YOU be so POMPOUS to call me a liar! Put that in your ignoramus hat and wear it!

Believe me or not - this stuff happens- and you are the one with a real combative problem. So go fight with someone else!

Anonymous said...

Teresa said on April 23:

But then, to allow general anesthesia is to make yourself completely vulnerable to a bunch of people no matter what. In general I find it disconcerting that I cannot establish a trust relationship with all of the people who would be involved in surgery, so the whole notion creeps me out.

Guess it's ok for YOU to be creeped out but not the gal who posted about the clinical research?

You need a reality check-up~

Teresa said...

Anonymous, your logic and communication skills are too poor to continue this "discussion" in any meaningful way. I think careful readers of this blog will see that. I stand by everything I have said in this thread, particularly my April 23 comment.


If you spend word for word with me, I shall make your wit bankrupt.

-- William Shakespeare

Anonymous said...

Match wit? I don't think so.

You don't even know how to follow a thread correctly-

You don't take into consideration that there are more than one "anonymous" posters here - because you quoted a different anon - [who was actually disagreeing with me]and blasted me with your response to it.

"Unfortunately we don't live in prefect society where everyone can do a prefect exam just by reading about it and without any practice."

I did NOT post that - You attacked someone who was posting to me~

I am ending this here -- because you are the type of poster who feasts on negativity and your combative nature is repulsive.

Teresa said...

"Unfortunately we don't live in prefect society where everyone can do a prefect exam just by reading about it and without any practice."

I did NOT post that - You attacked someone who was posting to me~


I think it was very clear to everyone that you did not post that. I was responding to him in that section of the comment, and that's why I quoted him. I disagreed with both him and you. Possibly you are having trouble with that concept because he also disagreed with you.

You really do have trouble with communication.

Match wit? I don't think so.

I cannot argue with that! ;)

Anonymous said...

This is a follow-up post to those who responded with at least a minimum of courtesy to my initial post on the subject of medical ethics.

But first, it should be noted that this blog board has a mission – and that is for the blogger to post and receive responses to his comments on his opinion of medical issues.

It is expected that posters will conduct themselves appropriately and at times respectfully agree to disagree. Most posters adhere to that.


However, superiority complex driven psychos like Teresa -- take more pleasure in pounding a poster into a bloody pulp if their issues don’t fit into her weird sense of logic.

Especially by saying an idiotic and reckless thing like :
“ seeking care from a doctor, you've sort of granted a lot of permission, anyway, especially for a surgical procedure”.

She essentially called me a liar – that I was under anesthesia for many hours - and doubted that I had been subjected to disfiguring surgery - and I don’t take kindly to that.

Therefore, to those who commented with some courtesy--- HERE is the outcome of my final inquiry about suspicions of surgical "battery" while under anesthesia:

I had to follow my own suspicions of my injuries [instead of going on with my life as someone here suggested I should]
I just came from a surgical specialist who said not only did the other surgeon remove my pectoral major muscle but the minor also – along with axillary clearance and chest wall tissue. All without my consent. [wonder how long I was under anesthesia for all that?]

Since he said this is not the standard treatment for simple mastectomy for DCIS, he was devastated in having to inform me that none of these dissections were recorded on the operative or pathology report!
So much for medical ethics~


This surgery has left me in a mutilated condition - but with God's help, I will have to learn to live with it because there is nothing he can do to repair the damage~

Whether anyone agrees or not - Yes I will do what I can to make this surgeon lose his license!

Therefore Teresa: After you "check the logic" and "poor communication" of my post -DO NOT EVER post to me again. If you do, I will email the owner of the blog tht you are harassing me.

California gal

tyro said...

Leave me out of this. You two, or three, or whoever, have to hash it out on your own. If it gets too bad I will have to moderate, but I'd rather not.

I think this thread has strayed from the original intent. For anyone discussing harm they underwent, it sounds well beyond the scope of good patient care. The exam discussed in the post, though perhaps a point of discussion, is something that often occurs (exams under anesthesia, pelvic or otherwise) during the course of surgical cases.

There is a case to be made that a doctor in training participating in the case should absolutely participate in the exam as they will gain information not available without anesthesia; my problem was whether or not the patient had been completely 'informed'. That said, I didn't think this was a case of malpractice. What one poster described here might be. Medical students, which I was at that time, perhaps not so much.

EUA does not refer only to a pelvic exam. I've also done EUAs especially on orthopedic patients; these are incredibly revealing as normally pain prevents a good exam of the bony and ligamentous structures. Those exams pose no risk to the patient that I can think of. A pelvic EUA does not pose a risk either, just an issue of trust.