Saturday, May 17, 2008

Students and Sedation

"Your time in the OR can be especially valuable because of the quality of pelvic exams you'll be able to do while patients are sedated."
Caution: squeamish topic ahead...

Last week, I wrote in The Differential about the blurred line in the operating room between humor between physicians and laughs shared with patients. With another week comes for me another state, another clerkship, and another uncomfortable situation in the OR.

Learning the pelvic exam is an important part of medicine. As a doc in a busy ER, I bet I'd average one a shift. But who wants a student doing their exam? Any manipulation downstairs is one that needs to be done with respect and professionalism. There are gender issues, privacy issues, and the question of whether the exam is medically indicated. (Many docs subscribe to a policy of giving a rectal exam to every patient with gastrointestinal problems or anal pain - a colorectal surgeon I recently worked with thought otherwise.) In the context of these issues is the fact that students don't have a clue what they're doing when they start doing exams!

Med students learn these important exams first with paid healthy volunteers (NOT each other!), and graduate to willing patients. With rare exception, a student's exam will need to be followed by a resident's or attending's exam. Two for the price of one. Would I volunteer? Many patients do not.

Which brings me back to the quote above. When a woman has a hysterectomy or other gynecological procedure under general anesthesia, it is very important to know where the uterus and cervix are. The patient has agreed to having a student in the OR, so implicitly agrees to an exam. The pain from the procedure far outweighs any discomfort caused by a pelvic exam, and the anesthesia leaves the patient without a trace of memory from the exam.

So why am I still uneasy about performing a pelvic exam on a sleeping patient? Strangely, I'm more comfortable with someone conscious. But I bet I need the practice.


Ms. SuperScience said...

Ew. Maybe it's just me, but the thought of that being done while I'm under anesthesia kind of creeps me out. Like the dentists who advertise complete sedation dentistry - I'm sure it's great for some people, but I prefer to feel as if I know what's going on and have at least some control over it. So I'm probably weird, but if I were given the choice between having an exam while under anesthesia or having 2 exams done while awake, I'd take the 2 any day. It's about the illusion of control for me, I guess.
And now I'm a little afraid of my upcoming sinus surgery. Thanks a lot :)

thomas said...

I do hope no one performs a pelvic exam on you during your sinus surgery! (I guarantee that won't be done...)

But just to clarify, it IS important to do a complete exam under sedation in order clarify the anatomy of the relevant structures.

Thanks for your comment!

Anonymous said...

An sedated woman is not a hand puppet. Ask FIRST. You would ask permission if she were concious. You must ask permission on the form. Or practice on each other if you find it so banal...