I followed my resident into the patient’s room so that we could introduce ourselves before the surgery. We chatted for a bit about what to expect, and at the end of the conversation, my resident said: “Before we remove your intrauterine device, we do a pelvic exam to check you before we begin. We usually have the medical students do this with me and our attending right there since they are learning. It is a great opportunity for them. Would you be okay with our student doing that?” The patient took a deep breath and looked at the white wall ahead, and for a split second, it looked like some past memory she had attempted to lock away re-surfaced.
The patient then looked into my eyes and asked, “How many of these have you done?” Before I had a chance to answer, my resident jumped in avoiding the question and reinforcing that both she and the attending physician would be supervising. Should it matter how many I have done? The patient later denied what would have been my first pelvic exam, and I did not think much of it since it had been a common trend.
In the operating room, we were preparing to remove an intrauterine device. My resident motioned towards me to drain the bladder. “I drained 200 milliliters,” I proudly stated as I handed her the bowl.
As I got up to switch places, the attending handed me a speculum and said, “Here, you want to visualize the cervix for us?” I was happy about the opportunity, but I realized seconds passed and I had not moved.
“What’s wrong?” asked my resident.
I asked myself the same question. I was excited, but it did not quite feel right. Technically speaking, they did the pelvic exam already. So this would be fine, no? Medical students usually do this, and I need to learn for the future. At the same time, I could not shake the image of the patient’s facial expression when asked about having me do the exam. I could get off on a technicality, and surely my resident remembers the conversation and she has not said anything; it is probably fine. But I knew. I knew that had we asked the patient about allowing me to visualize her cervix she would have said no. That has to mean something. How is this different from other typical medical student duties during surgery? We do not always consent for all that we do. I have never seen patients deny any of the other stuff like closing port sites. If it is part of the general consent, why has a patient never denied that?
So there I was standing with the speculum. “The patient said no to me doing a pelvic exam. I guess this is different, but it just feels wrong,” I said. My attending and resident looked at each other.
“Oh yeah she did say no to that, but this is different, right?” said my resident.
“Honestly, consenting patients for a pelvic exam in the operating room is a relatively new policy, so I do not know. If she said no, then I think it is better if you do it.”
As I walked home, I thought about my surgery rotation, all the port sites I closed and the cuts I sutured. Often, the patients were asleep when I did that, but some of them were awake and watched me suture their abrasions closed. I did not ask for their permission. Maybe they would have said no? But they knew I was a medical student, and they saw what I was doing. I guess at a teaching hospital patients know that residents and students participate more, and maybe it is part of a consent that I do not see. If I was running a teaching hospital, I would just have all patients sign a consent form that says, “Medical students and residents do stuff … If they do, they will be supervised appropriately.” But I do not run the hospital, and I do not think that is part of the deal. Nonetheless, something today seemed different compared to the other situations. Maybe it is exactly the same and it is just a feeling. And yet, I know my resident and attending went home today without giving this situation a second thought while I have thought about it all day.
After some thought, I realized that I should consider thinking of consent as having two different parts. The first part is the paper that is signed for legal purposes with an explanation of most likely outcomes and complications, but the second part is understanding what is important to the patient so that the medical team can act accordingly, especially in unanticipated circumstances. In the case of this patient, my feeling was regarding the second part of the consent since I knew what the patient would and would not have wanted. In general, I think that the second part of the consent is much more difficult without having a previous relationship with the patient. However, I still think it is my job to try and do more than just the first part of the consent: And, above all, act accordingly when it just does not feel right.
Image credit: Supplies in a delivery and operating room by World Bank Photo Collection is licensed under CC BY-NC-ND 2.0.
Resident Physician Contributing Writer
Henry Ford Hospital
Max grew up in Los Angeles before going to Undergrad and Medical school in Chicago. Max is currently a 2nd year Emergency Medicine resident at Henry Ford Hospital in Detroit.