Monday, March 8, 2010

I can't really think of a tasteful title for this post

Anesthoboist has posted this, which is about a number of things including pelvic exams.

There has recently in Canadian newspapers been a flurry of stories and denials. This is based on the "discovery" that medical students and junior housestaff perform pelvic examinations on anaesthetized patients who haven't consented for this. There have of course been denials from many Professors of O and G who have all stated that they would never and have never allowed medical students to examine patients under anaesthesia without their consent.


I went to Medical School at one university, interned at another, did my residency at a third and now work affiliated with a fourth and unless all of these four programs are an anomaly, women across Canada are still being violated in the name of medical education. I witness it just about every time I do the gynie list.

Now for those going into gynaecology, family practice, urology and possibly general surgery, the ability to do a pelvic exam is a necessity. Actually with "advances" such as ultrasound, being able to pick up an ovarian mass, fibroid or enlarged uterus is less important and I have never understood why it even matters whether the uterus is anteverted or anteflexed. It is of course important to be able to do a Pap smear (which students don't do in the OR) and an endocervical swab for STDs (also not taught in the OR).

When I was in medical school we learned pelvic exams on volunteer women. These were from what was called the "Women's Health Collective" who had a mission of teaching a largely male class to at least do pelvic exams in a way that would be quick and painless. Remember at that time half of us were going to be general practitioners. It was a good if somewhat uncomfortable experience but we learned stuff like doing a "neutral touch" first, draping and warming the speculum. Some of the women were apparently on social assistance so it was disconcerting to see the instructor pay them in cash at the end the session so they wouldn't lose their benefits. At that time about 20% of the population didn't have medical coverage so some of them got their care at the hospital gynie clinic where they got seen for free by residents and medical students. Actually that resource was drying up (figuratively not literally) by the time I was a student.

And of course we examined women under anaesthesia. You didn't scrub on a hysterectomy without being asked (told) to do it. We were even encouraged to go to the abortion list so that we would learn to "appreciate" the uterus in early pregnancy. (Just so I don't get shot through my window; I didn't actually do any abortions).

Men were not spared although prostates didn't get nearly the attention that the uterus got. I have been forced to do a lot of disgusting things in the name of education and of medical care but this story still stands out.

We started our clinical exposure in the second term of second year. We started out with a course of physical examination skills. As we were told no examination is complete without a rectal.

At that time Vancouver General still had some of the huge open multi-bed wards you see in old movies. One such ward was the male urology ward which was known as the "Penis Palace". Apparently men with urological problems don't need any privacy. Our medical school had undergone a rapid expansion in numbers to fill what was felt to be a shortage of doctors (when we graduated and actually tried to practise, they told us that no there were actually too many doctors but I digress). Unfortunately teaching resources hadn't kept up with the increased numbers of students so what were supposed to small clinical teaching groups had become bigger. There were 9 of us in that group that day.

We were being taken around by a urology resident who quite clearly would rather be doing anything but teaching medical students (something I now understand). An elderly man had been admitted with urinary retention. Examination of his prostate had revealed the classical prostatic nodule. Conveniently he was an alcoholic which meant that he was in a state of delirium by the time all 9 of us arrived. This hopefully made it easier on him when all 9 of us one after the other stuck their fingers up his bum and wiggled it around trying to appreciate the prostatic nodule we were told was there.

All in the name of education.

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