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Are Portland V.A. patients being used and abused for the sake of training OHSU residents?

Do some OHSU Drs. treat V.A. patients in a way they would not treat OHSU patents for fear of legal actions? Read the following letters comments made on a medical student chat board and you decide.
Dr. Collins brings in male student at last min against patients expressed will
Dr. Collins brings in male student at last min against patients expressed will
Are Portland V.A. patients being used and abused for the sake of training OHSU residents?

The media has focused on vets access to medical care, and claimed the quality of care is just fine. I beg to differ. While the quality of health care is generally poor in America, Vets are between a rock and a hard place concerning medical care. There are some excellent Drs. working at V.A. facilities and I am lucky to have a great primary care physician, there are also Drs. that are not so good, and others that may even be abusing V.A. patients in their own interest. When you get sick enough to need specialty care, you are exposed to a larger number of practitioners; thus, your odds of drawing a poor and/or abusive physician increase under conditions where great harm can be done. It has been conventional wisdom that vets may improve their odds of quality care if a V.A. medical facility is joined at the hip to a teaching facility such as is the case with PDX VA and OHSU.

I was reminded of a story told to me by an old C.N.A. who used to work a V.A./teaching hospital. This resident happened to mention that he had not "done a hernia", the surgion proptly began going about raising the gowns of old men until he found a hernia (a small one that did not require surgery and the man was very old), and ordered the prep and "trained" that young resident proper. The most present lesson? Poor elderly V.A. patients are little more than a cadaver.

What occurred above is patient abuse pure and simple, it is wreckless endangerment, and if the man had died it would be homicide. So why did he feel so free to do what he did? The odds of him suffering any repercussions are relatively low when the patient is a V.A. patient. OHSU is sued by the public on average of 23 times a year for malpractice. At this point in my research, under the umbrella of the V.A. they seem to have suffered none.

While this sort of risking harm for the sake of teaching puts all vets at risk, women Vets, may find themselves not only put at risk of physical harm, not only physically assaulted in the name of "teaching" OHSU residents at the PDX V.A., but also at risk of having ones stated gender preferences violated in the most vial ways.

Many women, history of assault or not, prefer female doctors in certain situations—OBJYN, surgical procedures such as mastectomies or colonoscopies. Given the historically evident risk of assault women face while under sedation, this is a time when more than the gender of the physician, but the gender of the nurse may be relevant. In the case of GYN surgery such as an oopherectomy a women may not want men present at all.

Here is one story that illustrates my point as told through a couple of letters to PDX VA Chief of staff.


V.A. Medical Center, PDX
Chief of Staff
Dr. John Dryden
P.O. Box 1034
Portland, OR 97207

I have some concerns regarding my care at the Portland V.A. While both my husband and I have repeatedly expressed to several staff members from bottom up, (from C.N.A. to DR) that I am not comfortable with men being involved in my care if that care involves exposure of sensitive areas, I am not evidently being heard or understood clearly. I have been in O.R. a couple of times in the last year. I am not at ease with being unconscious generally, and very uncomfortable with the presence of men during unconsciousness and/or procedures the likes of these two events. The first event was a mastectomy/bilateral oopherectomy on June 18th '07, the second was a colonoscopy on Dec. 12th '07. I had done my best both times to ensure I was not only in the care of a woman, but women, that is that not only the surgeon, but the entire "team" was female. Both times I asked and understood that not only was the person performing the surgery, but also all in the room would be women. Neither time did this turn out to be the case.
In the first case this may be due to a difference in understanding the term "team" in conjunction with a failure upon the part of the V.A. policy to respond fully to the needs of many women who might specifically request female Doctors. In spite of asking and being told that we were going into the O.R. with, "an all female team", in the case of the mastectomy/bilateral oopherectomy a male Ronald J Gschwend was involved on the prep team and support staff during the surgery; according to the record he seems to be in the room during the entire prep and all three operations. Given the exposure in such a prep and surgeries; I am not happy with this situation for two reasons. One being unconscious, I cannot KNOW that I was never in the room alone with him at any time before, between, or after surgeries, and secondly the overwhelming eroticisation even comodification of violence against women in this culture ensures that I can never be assured that such procedures as a mastectomy that comes at a very high price for me will not be an erotic experience for a male. For both these reasons I am upset about Ronald's presence. I am also not happy with the fact that a Jeffery J. Hoke seemed to be in charge of my care in POCU for well over an hour while I was still under the influence of sedation. I awoke in a Room to find no women around (there did not seem to be a woman on the ward that night) and men in charge of my care. My husband was there so I said nothing at the time (didn't seem to care until latter when the sedative had worn completely off.) My husband did at that time warn the male nurse that I would not like this once sedation wore off. It seems to me if a woman makes gender specific requests, there is good reason to assume a need for this gender specificity to apply from the top all the way down unless the patient indicates otherwise.
It appears to me that a Dr. Shabnam Chaugle MD is listed as the surgeon and Dr. Kwan as attending on the mastectomy. (Kwan has assured me she did the operation, but according to the records this is not the case.) I do not remember being introduced to any Dr. Chaugle but based on a Google, this person was a Resident at OHSU, who is now in California. It also appears that Dr. Chaugle is a woman, but I am not sure this info is accurate. My husband told me that a male in scrubs introduced himself as assisting; but after reviewing the medical records, I have come to the conclusion this must have been Dr. Chaugle or perhaps Dr. Galic, and that, he was simply mistaken about her gender. I find this sort of bate and switch to a relatively inexperience resident at the last minute a problem itself when a procedure is blown (in case of the massectomy/oopherectomy it certainly was not), if gender is also switched in the process, as occurred with my colenoscopy on Dec. 12th. , it is even more complicated. Again as in the case of the first surgery, I requested a woman when I made the appointment, was introduced to Dr. Judith Collins, and told this would be the woman doing the procedure, asked and was again assured it was an all female team. Again this turned out not to be the case. After I was prepped and in the O.R. room a young male Dr. Mitchal A. Shreiner was introduced to me, and I was told he would do the procedure. Dr. Collins told me in the phone conversation I had with her latter about the issue she did in deed understand that I wanted all women present. She did apologized for bringing Dr. Shreiner's in when she was well aware that I did not want a man present. Also, however, and perhaps more of a concern to me is how in both cases (June 18th and Dec 12th) men were involved in my care on a lower level. On 12/12 there was also a male "tech" that introduced himself, identified his job as transport of any tissue to lab, and said he would be on the "other side of the door unless needed" and then preceded to remain in the room the entire time. During my phone conversation with Dr. Collins she confirmed that I heard him correctly, that he said he would be on the outside of the door unless and until needed and could not account for why he remained in the room. When I looked at him like what the hell are you still doing here, rather than asking him to leave, Dr. Collins tried to reassure me by blocking his view with her body, but that only lasted for a short while until she had to "step away". I am very upset that he stayed in the room and this issue I would like to be addressed. Why did this man lie? Why did he stay in the room? He obviously knew I did not want him there, yet he lied to get consent for one thing and did another. I am not sure this tech's behavior legally amounts to sexual harassment, but from my standpoint this is at least a case of sexual harassment. Being introduced literally seconds before the procedure, I did not feel I had the power or time to object. (I did display behavior that was evidence of my discomfort, however, including trying to cover up when left in his full view. That is the last thing I remember before being rushed out the door to go home. I cannot even remember being given the post op instructions, but then neither does my husband.) I see no reason for his being there. The attending nurse could have easily handed any tissue that needed transport (his stated purpose for being there) out the door. WHY DID HE STAY???

The next day I noticed signs of much more physical trauma than I expected—excessive bruising in the area (a deep blue circle all the way around my anal cavity extending out about an inch beyond the opening, and continues into the canal), as well as, pain both in the local area and lower abdomen. A few days latter I talked with a breast cancer friend I call when I need understanding. She had just had a colenoscopy a couple of weeks earlier and she said she had no such trauma immediately concluding I was assaulted. Now, I do not know this to be true; however, given no other explanation I do not know what else to think. Dr. Collins could think of no reason why there should be such trauma from the procedure.
However, it is logically unavoidable that either:
1) Dr. Collins not having done a preliminary exam is unaware of some condition that may have caused this and likely should have also then eliminated me as a good person for Resident training. (Which in my opinion any patient currently suffering chronic pain is not a good candidate for training risking the infliction of further suffering.) or,
2) Dr. Shreiner needs to fail that procedure, be taught better on a couple of cadavers and then try again on a living human. Dr. Collins insists he did just fine. He certainly seemed to be doing ok as I went under; but something went wrong somewhere, or,
3) I was assaulted while under sedition. Dr. Collins assured me that it is PDX policy to have a female nurse present the entire time a woman is under sedation, but I am not confident that protocol is consistently followed, nor that Dr. Collins would know if it were not. While I was told that the female nurse who was supposed to be there the whole time would call and assure me that she did indeed follow that protocol, I have received no such call. I would like to talk with her. I do not know her name, and again as in the case of the tech, I was unable to find it in the records. (This indicates to me other people could have been involved including men and their names would not necessarily show up on my records.)

Again, I do not know why the extent of the physical trauma. It is my lack of ability to KNOW what occurred in conjunction with knowing things did not occur, as they should have that concerns me. (I was traumatized when I did not go under during a colonoscopy four years ago, but to go under and wake up harmed is worse.) I certainly think an investigation is warranted. Why did this man stay in the room? Who had any contact with me before I was returned to my husband? What are the professional and criminal histories of these people? Did opportunity present itself? Why am I so badly bruised? I want to know did the resident under Cr. Collins supervision (or lack of supervision if she left the room), botch this colonoscopy or was I assaulted? Relatedly, unless Dr. Collins can KNOW beyond a shadow of a doubt that nothing occurred and in the absence of any explanation for the level of physical trauma, it seems to me I now need to be tested for STDs before returning to active relations with my partner. Thus, I would like an investigation into whether or not Dr. Collins or you can GUARANTEE no need for concern, and inform me of the results. Did both Dr. Shreiner and the "tech" leave the room before or with Dr. Collins? Did Dr. Collins leave the room while either male was still in the room? Did either of them return to the room? Was I ever left alone or in care of a man or men during or after the procedure? What is the history and character of this nurse? What is her name? I would like to talk with her. WHAT HAPPENED???? Why am I hurt???

I understand that I am writing a male Dr. concerning this issue, which guarantees you will not be able to understand this on the level I would like and may even find my preferences sexist and certainly inconvenient for male colleagues, perhaps even staffing. From my perspective, given not only my personal experience, but the experience of many women in the world and nation wide, in conjunction with the fact that Oregon has a higher instance of sexual offenses against women under sedation in medical care than 40 other states, indicating a lack of sufficient law and/or monitoring to guarantee women's safety; it is essential to my security to never be left alone in the care of a male while under the influence of anesthesia. I understand that such sex specific criteria will not guarantee the absence of an inappropriate event (women abuse and silently allow abuse); it will certainly decrease the odds.

In addition to the unexplained physical trauma, or should I say even in the absence of this physical trauma, I would continue to feel distressed over the presence of male "techs" during these procedures. If the general population of breast cancer patients feel anything like I do, cancer itself leaves one a bit out of control of ones life and even body. In this case, it seems to me, a lack of sensitivity training and adequate policy or enforcement has exacerbated this feeling (rather not just a feeling but actual reality of lack of control). Doctors are in a habit it seems of bringing Residents in at the last moment. (I am starting to suspect this is because if they give us time to think we will not consent, either to a student or a male.) As stated before, I suspect it may well be that pushing the limits of my tolerance for men in such situations benefits education and keeps from complicating staffing; but it has taken an emotional/psychological toll on me that is not acceptable. If a woman expresses a preference for female Doctors in general or in relation to a specific procedure, it should be assumed she has a reason for such a preference. More questions need to be asked to see how deep that sensitivity goes and how best to accommodate the patients medical needs in a way that will allow her to get the care she needs without unnecessary psychological discomfort. The way it is being done, (ask nothing just bring the men in at the last moment; if she does not assert herself enough to throw them out, she must not mean it when she claims she does not want men present or involved), not only is it similar to rationalizations for sexual assault, it lends itself to an attitude that is conductive to assault, a hostile environment if you will. It amounts to an attitude of people as objects rather than free subjects, giving staff the idea that stated preferences do not matter if she does not yell or stop her feet (or if you think she will not remember doing so) keep going. Also, some of us experience this lack of consideration of our expressed preferences while under sedation as sexual assault, and repeated requests by staff to include men while in the men's presence as sexual harassment. It is a problem when Doctors feel more compelled to take you into a private room to talk you into a procedure they think you may resist (this has occurred several times) but do not seek the same sort of meaningful informed and expressed consent when they bring in a male and/or student knowing you may be resistant. I am either, never told men will be present and may or may not find out from my charts, or men are brought in at the last minute, after prep after in the O.R. when it is much harder to protest, and drugs may have been administered, "to help you relax". At this point it seems to me, women's expressed limitations regarding male participation are being intentionally pushed, even ignored.

From the perspective of a sensitive woman and patient, I would suggest that policy change to something akin to:
1. ALL women who are to undergo a procedure requiring the exposure and or invasion of sensitive areas (breasts, vagina, anus), are asked what their comfort level is;
a. Ok w/ specified procedure(s) performed by males
b. Not ok w/a. but ok w/ male support staff being present during procedure, involved in prep, or post op care.
c. Not ok with male presence of any kind during specified procedure, prep, or post op.

I have been assured it is policy not to leave women alone w/any males while under the influence of anesthesia, regardless of perceived or expressed patient comfort level. If this is the case, make sure it is strictly enforced. If it is not the case; it should be.
2. Only in an emergency effecting patient health should such gender preferences as described and reported by patient be violated.

Please do not tell me to go to, "patient advocacy"; I called them and was told that due to the nature of my complaint I needed to write this to letter to the "Chief of Staff".

Beyond the requests made above, what do I want?
1. While the above events are the most disturbing I have experience of late, they are not isolated. I was open to some exceptions (male students who I was introduced to ahead of time, had a chance to talk with and then asked to approve or not by the female supervising Doctor after the male student has left, so I can speak frankly about how I feel concerning his participation). However, given the fact that if I am asked at all I am not being asked ahead of time (before prep, before the administration of any medications even a mild tranquilizer, before being taken to the procedure room), and given the fact that when I ask and am assured of an all female team up to moments before the procedure, yet can have no confidence that this will indeed be the case, I not only want the flag in my chart as Dr. Collins suggested, but I want a member of my family present at all such procedures including O.R. I realize this is unconventional, but at this point, after so many lies, and now there is this unexplained physical trauma, I have no trust of your staff male or female from C.N.A. to Dr.
2. I would also like the name of the tech on 12/12. I remember his face, but I want to know his name and have it put in my charts that he is never to be involved in my care in any way what so ever in the future. I feel very strongly about this. Education, staffing, there was absolutely NO valid reason for him to stay in the room. He was getting off on doing so; he could, so he did. If I had the power, I would fire him. (As an old labor activist I do not say this lightly.) I would applaud your doing so, but doubt I will see this satisfaction unless I am not the first to complain. He lied, and did so intentionally and smoothly; at the very least I would like a write up on the event in his personal file. Then, in case such behavior is repeated on his part, there will be a record in his personnel file making the pattern evident.

3. I would like a min-by-min account of what occurred 12/12 during and after the procedure. I would like to know what medications where administered and when. (The records on 12/12 seem incomplete from the exclusion of this tech's name to the absence of notes on prep complications and a bad decision to administer a third bottle of fleet.) If there is any sort of recording of the procedure I would like to hear it. I DO NOT want you to withhold any information you may discover for any reason, including that such knowledge may negatively affect my health physically or psychologically. (If you have been following the recent case in PDX you will know that a higher court has now overturned the lower court declaring that patients do have a right to know if they have been assaulted, in spite of perceived psychological/physical harm.) Also, given this administrations use of Verichips, and expressed desire to expand that use, I would also like to know if any kind of chip was placed during either procedure above. Aside from the obvious problems with such a practice, these chips have been proven to cause cancer.
4. I would like a referral to a private physician of my choosing to do a follow up exam to check for physical damage. (I am still suffering abdominal cramping and canal discomfort, and spotting.) Dr. Collins volunteered, but at this point I would like an independent examination. Unless you can guarantee it is not necessary I would like the same to be done in terms of testing for and STDs. I cannot afford to pay for this myself, and it seems to me outside/third party care only makes sense in terms of these two requests. The V.A. should pay for this, and I should still be able to choose my own Dr. or clinic.

While in the V.A. health care system I have received both the best and the worst of care. In many ways the V.A. system is the best American health care has to offer. If my experience of late is any indication, however, much work still needs to be done in terms of women's health and safety. I am looking forward to hearing from you.


After another encounter w/Dr. Collins and reading updated notes in her medical records, this woman writes another letter before she hears back regarding the first. That letter follows.

V.A. Medical Center, PDX 1/22/08
Chief of Staff
Dr. John Dryden
P.O. Box 1034
Portland, OR 97207

Dr. Dryden,

This is a follow up to a letter I sent to you (forgot to date but) you rec'd on 1/9/08 I would like to make an addition to my complaint referred to above. I am not sure why my follow up was with Dr. Collins rather than Kingge other than this gave her an opportunity make misleading notes to out and out lies in my chart in an attempt to cover her own back side, an attempt that ends up providing further evidence of her incompetence and raise more questions regarding her medical ethics and what happened on 12/12.

First are the conflicting notes. While the notes I previously obtained on 12/13 stated that both prep and procedure where "uneventful", and claims of "no complications" were made in notes by Dr. Schreiner, and verbally by Dr. Collins in phone conversations and at the appointment on the 16th," in the notes following that appointment Collins now claims, the procedure was "quite difficult from prep onward". She does not elaborate. The failure to elaborate may be because the difficulties were a direct result of Dr. Collins' incompetence.

Indications of incompetence:
The prep was problematic as a result of Dr. Collins not allowing enough time for the laxative to work. It seems to me the low digestive motility indicated more time be allotted; but instead she insisted that I needed a third dose as I had previously thrown up some of the a.m. dose. I told her I did not throw it all up and felt what I had thrown up was due to consuming too much already; but she insisted I needed a second a.m. dose indicating that it would be a shame to have to start over again another day. Not wanting to go through the prep again, and living 5 hours from Portland, against my better judgment, I acquiesced and WAS OVERDOSED. 10 min or so after the last dose, I really started throwing up. This may account for some of the difficulty in OR if I continued to heave during the procedure, but I have never been told this was the case. Also, I told them not to put a tube down my throat as I had a serious gag reflex problem; if they did so, knowing my own history, I have every reason to believe this would have further complicated things. It certainly did the last colonoscopy that was done four years ago concurrently w/a UGI.

The procedure was 45 min long. This is unacceptable!!! Why was a procedure that should have lasted 20 -30 min tops going on for another 15 min? When I asked Dr. Collins about this, she once again said the procedure was uneventful and indicated that I should find comfort in the fact that is was thorough. This is in reference to locating cancer; but if this can be achieved for the mass of cases in 20-30 min, being thorough cannot explain 45 min. What, is everyone else getting a cursory exam? An exam this long for the sake of training is patient abuse.

Most of your staff members seem to be able to read charts. The pain clinic seems very good. What is wrong with Collins and her fellow? After repeatedly telling these people I am not using pain medication as a result of an impaction, their conclusions continue to hypothesize pain medication use as a factor. Furthermore, Dr. Collins seems to think the GI issues are recent, starting A.I. use. This is simply not the case and she should know this if she had read my chart. I do not like medications and for the last 10 years have not taken medications until recently, but this condition has been consistently present and progressive over that same time. Unless it has something to do with a past medication such as Serizon, which I have previously inquired about and was told there is no relation, it is not likely med related. Also, indicating an unwillingness or inability to effectively read charts she stated in these same notes that I never had a UGI, which I did four years ago.

Indications that Dr. Collins is not an ethical practitioner:
The notes Dr. Collins put in my charts on 1/16 do not reflect the facts, not even as she knows them. Dr. Collins knows that I never gave permission for the male tech to be in the room save to receive tissue samples if needed. She admitted this over the phone and stated she did not understand why he stayed in the room. As I stated before, his stated purpose was transportation of tissue and he promised to remain on the other side of the door until needed. Dr. Collins knows this and what she was willing to admit to me over the phone is not reflected in her notes; in fact she provides conflicting statements. I never gave permission for him to participate in the procedure, "suctioning" or other wise. Dr. Collins knows this, and has previously admitted to this understanding, yet now Dr. Collins' states I did consent to him being in the room and his participation. I assume this is to cover her butt, and thus he did indeed participate in the procedure. Why was he needed for this if there were two Drs. and a nurse in the room? From what orifice was he suctioning, and why was the nurse not doing this? Why is a "tech" doing this? He was not even scrubbed. If there were extenuating circumstances that indicated he be used in such a capacity for which he is not qualified it seems such circumstances warrant a note in the chart and a post op explanation to me. Dr. Collins claims she informed me that, "JECHO requires a tech" she did not and if she had bothered to talk with me in that sort of detail I would have rejected the male tech. If she had asked if a "trainee" could do the procedure I would have said no regardless of gender. I was hustled pure and simple, and in the most vile way—kin to rape. Again Dr. Collins knew I did not want men involved and set things up so I would know as little as possible and know it as late as possible. This is not ethical.

Dr. Collins had many opportunities (including when I expressly asked, and when she had me in a room to talk me into an overdose) to ask about her "trainee" (he was introduced only as an MD to me, not as a "trainee", another of Collins' lies), and failed to do so until I was in the OR. While she states in my chart I was "OK" with these men being in the room; she admitted over the phone that she was well aware that I was not "OK" with it, (as I had asked for women and expressly confirmed less than 20 min prior to the procedure that this would be the case), at the time and apologized for moving forward in spite of this understanding. Furthermore this "request" concerning Dr. Schreiner did not come in the form of a question, but in the form of an introduction and the statement that he would be doing the procedure while shoving a paper to sign in my face. Laying down prepped for procedure is not a time when a patient feels they have the leisure to object, let alone to sit up ask for light and some glasses to read a document. I was never told a tube would be put down my throat; and had told them when they asked about a feeding tube that this would cause an ongoing gage reflex. The only reason I can see for this late request concerning the men, and the misrepresentation of the techs participation, is manipulation. If this does not break the letter of the law; it certainly breaks the spirit of the law concerning consent. Was a tube put down my throat? Did this still unnamed tech participate in the procedure? If so why? There were more mistakes made than the overdose and disrespectful manipulation and lies regarding the men here. Either Dr. Collins did not honestly attend the entire procedure, or she knows more than she is telling or entering in my charts, as the physical trauma remains unexplained. She seemed to present a hypothesis at the last appointment about the tub being curled when pulled out causing a descending colon. I did not understand what she was talking about; but my husband explained it latter. If this happened, who had a hold of the tube at the time? Why was I not told?

At this point it has become evident to me that Dr. Collins is a very poor physician. She does not read or interpret charts well, she does not listen to patents nor respect their perspective or feelings, and she is not good at making decisions. Furthermore, she is willing to lie to cover her mistakes, as well as what appears to be abuse of Vets for the sake of training her fellows. Certainly in the sea of evidence indicating incompetence the probability of the physical trauma resulting from said incompetence rises. However, such incompetence in a team can also lead to assault and thus this remains to be ruled out. She ignored my request men not be present and did what she wanted to do, and did it after she overdose me making me sick. She employed the threat of having to do it all again if I did not go along with her plan. Given the fact that I was lied to about the nature of the techs role, if he was involved in the procedure, I call that RAPE. If he was not involved it remains a case of serious sexual harassment and perhaps medical malpractice.

Your V.A. advocate (or so called "patient" advocate) assured me that it is only the sort of men that I would associate with that would rape; certainly no man she knew at home or at the V.A. This woman seems to think the real problem is that as I am not a Christian who associates with Christian men (FYI 70% of Christian men report "sex addictions"), thus undermining my faith in the goodness of men. She is ignorant, insulting, offensive, and certainly no "patient" advocate. She gave indications of bigotry and internalized sexism. She actually reminded me of what is referred to as a "silent partner" with all her claims of the goodness and innocence of men. Furthermore, I am sick of people indicating that only a "victim" would object to men in such intimate care. This is not true. Many young women raised by feminist are taught to avoid male practitioners to keep from being victims. I have heard more than one female practitioner inform me that she would insist upon women in such cases, not because she had been assaulted, but because she knew the men of which she was speaking on a personal enough level not to trust them. Also, why is it your staff seems to feel such freedom to dump their religious B.S. on patients; from this "advocate" to an oncologist insisting that whatever happens is "gods will" or part of "gods plan"? I find this highly offensive. Has the V.A. deteriorated as much as active military health care where Army Doctors are willing to hand rape kits over to perps.? Has the V.A. been infiltrated by crazy fundamentalist Christians as has reportedly much of the military?

Which reminds me I do expect an answer to the verichip question.

While I have no intentions of a civil law suite (I find them a bit restrictive if one wants honest dialouge and quick change); a lack of appropriate response to my concerns could change my mind. I will have these questions answered to my satisfaction one way or another. This includes a detailed account of the procedure as it was performed and every persons role in the room, (if it was taped I want access), a min-by-min account of all events and complications, all involved and in what way, including an explanation of the physical trauma. In spite of what your staff seems to want me to believe, effects have causes. I expect full disclosure. If criminal behavior is indicated I expect charges be filed and V.A. support in prosecution. I would also like to know what the qualifications/ training this "tech" has assisting in colonoscopy procedures. If policy violation is evident, then I expect an administrative response. To the extent that policy is at fault, I expect reform. My expectations are not unreasonable.

BTW, while Dr. Collins seems to minimalize the harm she has done, not only am I waking up every morning with this first on my mind each and every day, not only can I not watch a movie because I cannot keep these thoughts from creeping into my head and disrupting the flow of the movie, not only am I avoiding all including my family to keep from dumping this crap on them, but I STILL HURT!!! Yet the only follow up I have been offered is w/ Dr. Collins. If G.I. has anything constructive to offer I am desperate enough to return for Dr. Knigge. In terms of a follow up exam regarding any harm that may have resulted from the colonoscopy, I want this follow up fee based and I want to pick the Dr. so there are no conflicts of interests.

Patients Name


This same patient has been inspired as a result of the above experiences to do a little research on how the above story may fit into teaching practices in general and the attitudes these practices foster towards women.

Perhaps one of the most interesting finds is a web sites where student Drs. chat.
 http://forums.studentdoctor.net/showthread.php?t=82833

On this board a question is posed.

"From some personal experience and hearing stories from others, there seems to be a trend where male students are often being asked to leave during a Gyn visit. This seems unfair, especially to those of us interested in ObGyn. At what point do the patient's wishes get trumped by the need to train students?"

Of course the answer to this is at all points. Part of the lessons that need to be learned are those relating to respecting patients; yet many of these young students are being taught a different lesson.

This is one student's response, for example.

"this is the case at many schools, particularly if you rotate through a private hospital. If you are interested in obgyn (why??), try to rotate through a county or city hospital."

One could also assume V.A.

The comments go on to include a detailed explanation of how to manipulate women.

"have found that it really depends on the attitude of the attending (or the nurse) who presents the option of a student to the patient. On my FP rotation I was introduced to the patients as a medical student working with the physician, by the attending. It was said in a manner that implied this was the norm and was expected. He tells them this right on the spot, while I was already in the room. I was not turned down a single time. I am sure that some women would have declined if asked in a more subtle manner... .On the other hand my OB rotation and a few other electives, nurses would first ask a patient. I did not directly hear, but can guess that it was phrased something like " You don't want a medical student examining you, do you?" Or at least with that connotation."



"If it was a CLINIC patient, who almost by definition was either...
A) Coming in for free care (of course they're uninsured!!!)
B) "No Ingles..." (& can't bring someone who does!!)
C) On welfare with 3 kids by 3 different "baby-daddy"s
D) All of the above (more than 90% of the time)

I didn't even bother to ask. It is MY education, after all...."


"Well, actually...for me MALPRACTICE is a trivial issue...errr...actually it's a NON-issue as I am Navy HPSP with every intention of making Navy Medicine a career. I already have 6 years active duty...only 14 more 'till retirement

Not only will I NEVER have to worry about malpractice insurance, I also don't have to worry about student loans

Go Navy!"


What these young men, and educators of both genders do not realize it the heyday of doing as you will with women are over. This is pointed out by one responded who pointed to an ACOG news release, "The issue of physician gender is also an important criterion for women," Dr. Miller said. According to the Gallup survey, about half (47%) of the women surveyed prefer a female ob/gyn, while 15% state a preference for a male ob/gyn, and 37% say they have no preference." click here to read the whole article.

Just to show how strong some women feel about that preference, here are some of the women's statements at that same chat.

"Males aren't welcome into ob/gyn.... thats the bottom line"

"The patient's wishes NEVER get trumped by the need to train students. It's my cervix, thank you, and as long as I am conscious I get to choose who sees it."

"I had a pelvic done this week and the (male) physician came in, then the MALE nurse came in. I said: hey, why are you here, it's supposed to be a FEMALE in here with me.

The male nurse got nasty and said: no, it's only supposed to be a "nurse."

Silly me, I forgot I was in Utah, home of the MORMONS.

So even tho it was a teaching hospital and you'd think they were actually living in the 21st century, they apparently are not. Women are definitely second class citizens here, and the doctors are still men - for the most part. I was really very angry - they were incredibly patronizing and insulting towards me and it was clear that I had no rights in their eyes."

"You are the one who don't got it pal. Male gyno will continue to exist, but not abundantly. Like it or not gender is the issue here. No male doctor likes to think he one day won't have such access to a woman's body, but the fact is he is not, and don't you forget that.

You got it."

Women are starting to stand up and state, "It is our bodies and you boys have no rights to access, no matter what you may think. Push us more and see if we do not push back. If you do not understand that, you have no business in OBJYN, or medicine for that matter." The rape culture and what other men have done and do to women will have it's impact. This is not only going to affect your training, but your practice. DEAL WITH IT!!!

While not in the majority, there were very mature intelligent responses. Here is a mature response from a man that is suited for medicine.

"In the end, figured that each women could choose their own providers (and in my case observer) - Although I was really attracted to OB/Gyn I could feel the limitations as a male - In the end, my interest (and eventual application) to ENT told me that my practice would eventually be limited to just north of the clavicle. I just appreciated a side of medicine I would never see again. And loved every minute of it."

The point to all this is to pose the question is OHSU doing to V.A. patients what it cannot get away with doing to OHSU patients? It is this V.A. patient's opinion that yes, indeed they are abusing V.A. female patients, not necessarily in OBJYN, but certainly by one Dr. Collins in G.I.

the use of language to manipulate 26.Jan.2008 10:11

patrient

It seems the man introduced as the "tech" who would wait outside the door is noted in this patient's chart as the "assistant" Donald J. Miller. Of course an introduction with the word "assistant" would have set off a red flag right away. How many male patients are at the V.A.? Why the need to pick on a woman already suffering and expressing a preference?

Rape Culture at OHSU 29.Jan.2008 01:20

Just one more

If such practices as described in the letters and the comments by residents above are common practice at the PDX VA, then the very attitude that serves as the underpinning of this Rape culture, the very attitude that founds the sexual assault of female vets, that is the attitude that men have a right to access women's bodies over their objections, is shared by their medical providers.

THIS IS OFFENSIVE!!!!

time for intent to tort? 07.Feb.2008 11:43

it may take legal action to change things

Using tort law to secure patient dignity
JOHN DUNCAN, DAN LUGINBILL, MATTHEW RICHARDSON, and ROBIN
FRETWELL WILSON
Often used as teaching tools for medical students, unauthorized pelvic exams erode
patient rights. Litigation can reinstate them.
To the surprise of many people and the consternation of some medical school faculty and
students, a media firestorm erupted last year over teaching hospitals' practice of allowing
medical students to perform pelvic exams on anesthetized patients without their express
consent.1
This practice, common since the late 1800s,2 was largely unchallenged until a 2003 study
reported that 90 percent of medical students who completed obstetrics and gynecology
(ob-gyn) rotations at four Philadelphia-area medical schools performed pelvic exams on
anesthetized women for educational purposes.3
Although medical students performing educational exams on anesthetized women do not
receive feedback and thus cannot hone critical communication skills, teaching faculty
argue that being unconscious relaxes the patient's muscles, making it easier to palpate
anatomy, and spares the patient the humiliation of being examined multiple times while
conscious.4
As the controversy unfolded, it appeared initially that informed consent policies might
change for the better. The American College of Obstetricians and Gynecologists
(ACOG)—which tepidly defended the practice in 1997, asserting that patients have "an
obligation to participate in the teaching process"5—issued a one-paragraph statement two
months after the 2003 study was published, affirming the relevance of informed consent.
If the pelvic exam, ACOG declared, offers a woman "no personal benefit and is
performed solely for teaching purposes, it should be performed only with her specific
informed consent, obtained when she has full decision-making capacity."6
The day after the Federal Trade Commission and the Department of Justice heard
testimony on the topic, the Association of American Medical Colleges (AAMC), which
represents 125 accredited U.S. medical schools and over 400 teaching hospitals, issued a
three-paragraph news release that called the use of women under anesthesia without their
knowledge and approval "unethical and unacceptable."7
California enacted new legislation making unauthorized examinations a misdemeanor
and grounds for revoking a physician's license.8 Finally, a half-dozen medical schools
announced that they had voluntarily begun, or would begin, to ask patients for explicit
consent before medical students perform pelvic exams.9
Unfortunately, these early victories quickly stalled. At the same time a handful of schools
revamped their policies, an equal number of hospitals and medical schools publicly dug
in, defending the practice:
• Andrea Rapkin, a professor of obstetrics and gynecology at the University of
California at Los Angeles (UCLA) Medical Center, noted that while UCLA
doctors inform patients that they will be examined under anesthesia, they "don't
specify that it is a pelvic exam." She explained that "we have no reason to
specifically state that a medical student will [perform the exam]. It's not the
whole team of medical students—it's usually one or two."10
Last year, William Dignam, UCLA professor emeritus and former ob-gyn
clerkship director, elucidated why an explicit discussion with patients of student
participation is unnecessary: "I'm reasonably certain that patients know medical
students will be participating," adding, "it's pretty much covered in an overall
consent form."11
• An ob-gyn professor at the Medical University of South Carolina (MUSC),
Steven Swift, acknowledged that medical students who are directly involved in a
patient's care perform pelvic exams after the patient is anesthetized for
gynecological surgery. They do not secure specific consent for the exam, he
noted, as it is considered regular medical practice in the field, like helping with
surgical staples. Furthermore, he said, "patients understand this is a teaching
hospital and that residents and medical students are involved in their care."12
• John Larsen, George Washington University Hospital's ob-gyn chairman, noted
that he had "no plan to amend the hospital's policies. 'I'm a policy minimalist,' he
said."13
Clearly, relying on media exposure or government regulation will be slow going. When
the media loses interest, what incentive is there for teaching faculty or hospitals to
voluntarily change? Teaching hospitals take patients who are in the worst position to
know what's occurring—they are unconscious—and use them in ways that leave no
physical signs and are often undocumented in the patients' medical records.
Given the inherent secrecy of pelvic exams on anesthetized patients, hospitals and faculty
have yet to defend their conduct in courtrooms. This secrecy, and the resulting lack of
legal oversight and accountability, have reinforced the sense that doctors and hospitals
don't really need to obtain consent when patients are most vulnerable.
Although patients have been unable thus far to enforce their own interests, the tort system
may yet succeed in securing the right of patients to decide who touches their bodies and
under what circumstances.
The practice of using anesthetized patients to teach pelvic exams has been well
documented for years. A 1992 study showed that 37 percent of U.S. and Canadian
medical schools allowed students to use anesthetized women without their consent to
learn how to perform pelvic exams.14
In 1989, students at 25 percent of U.S. medical schools reported using female patients to
learn how to do gynecological exams.15 One in 10 was anesthetized at the time, and it is
unclear what, if any, consent was given.
In 2002, Stanley Zinberg, vice president of practice activities for ACOG, acknowledged
the long history of this practice, asserting that it was becoming "less common."16
Anecdotal accounts show that even men are not immune from the indignity of
unauthorized, invasive exams while anesthetized.17
Disputed numbers
The number of students who perform pelvic exams on a single anesthetized patient is a
significant element in making them actionable. Perhaps this is why teaching faculty
vehemently dispute the number. When asked last year by a regional newspaper, ob-gyn
residency directors in North Carolina invariably said that only those students on a
patient's "care team" participate in pelvic exams.18
Yet in 1997, a Duke University professor published narratives of medical student training
experiences that described as many as five or six students performing pelvic exams in
succession on a single anesthetized patient. As one student said, "[It was like] all these
medical students parading in to each take their turn, y'know, like going to a vending
machine, and walking by. Only it's not a vending machine, it's a woman's vagina. And
you're each taking your turn, walking by and sticking your hand in."19
Although it is unclear how prevalent this "vending machine" approach is, it is likely to
cause grave concern, particularly among women. One study of patient-consent practices
found that while women willingly consent to pelvic exams for training purposes, the
number of students involved matters a great deal.
Nearly all the women in this study, 84 percent, wanted to limit participation to no more
than two students.20 And in two different studies, all the women who consented to
student exams wanted to be asked for permission, regardless of the number of students
involved.21
Despite consistently strong reactions, apparently some faculty have not questioned the
practice. As Jessica Bienstock, director of resident and medical student education at the
Johns Hopkins School of Medicine and residency program director for the school's obgyn
department, noted, "I don't think any of us even think about it. It's just so standard as
to how you train medical students."22
Some faculty justify unauthorized exams by medical students as a vital and irreplaceable
part of physician education, to which patients would not consent if given the
opportunity.23 But research and experience have shown that patients are quite willing to
help with medical student training. A study in the United Kingdom found that 85 percent
of women who were asked consented to pelvic exams by medical students.24 In the
United States, only 39 percent of patients surveyed said that they would definitely or
probably object to a pelvic exam by a student while being cared for as an outpatient.25 In
fact, patients will consent to not only examinations, but also riskier procedures by
students: One study found that 52 percent of participants were willing to allow a medical
student to perform his or her first spinal tap on them.26
Researchers who have studied consent practices flatly reject the notion that medical
students will be starved of practice opportunities when patients are allowed to give
consent: "The small number of women who would not consent to vaginal examination
under anesthesia by medical students will not reduce our ability to teach gynecological
examination to undergraduates."27
When teaching normal anatomy, medical schools and teaching hospitals can always use
paid volunteers, called gynecological teaching associates; when teaching abnormal
anatomy, they could compensate patients. More fundamentally, as one researcher noted
about the common use of deceased patients for medical teaching purposes without the
family's consent, "the likelihood of refusal is hardly a justification for deciding a consent
is unnecessary."28
Theories of recovery
Performing a pelvic exam on an anesthetized patient as a training exercise for medical
students is not inherently tortious as long as the patient knows about it and consents. But
some teaching hospitals do not candidly inform patients about nontherapeutic and purely
educational exams that will be performed. Most hospitals make only general disclosures
like the following, taken from George Washington University Hospital's 2002 admission
form:
I have come to [this hospital] for medical treatment. I ask the health care
professionals at the hospital to provide care and treatment for me that they
feel is necessary . . . I understand that my health care team is made up of
hospital personnel . . . under the direction of my attending physician and
his/her assistants and designees (to include interns, residents, fellows, and
medical students).29
Many physicians believe that nothing more needs to be said, arguing that patients
"understand from the beginning that they are admitted for teaching purposes."30 But the
refusal to allow women to make informed choices about educational pelvic exams
implicates several possible causes of action.
For instance, claims for medical battery and malpractice, failure to obtain informed
consent, and breach of fiduciary duty could lead to recovery of actual and punitive
damages. Where the teaching hospital is state- or federally owned, a civil rights cause of
action may arise under 42 U.S.C. §1983. Courts may also be persuaded to issue
injunctions or make declaratory judgments that prohibit unauthorized pelvic exams on
anesthetized women.
Women who suspect that unauthorized pelvic exams have been performed will face an
uphill battle proving such exams took place and, consequently, changing the behavior of
large teaching hospitals. But the task is not impossible.
Medical battery and malpractice. As intentional, unwanted, and offensive touching,
unauthorized pelvic exams fall into the category of the most basic of torts: battery. Actual
damages are generally presumed in battery cases, and punitive damages are available
because battery requires intent by the wrongdoer. However, intent, whether specific or
general, is hard to prove, particularly where the wrongdoer is hiding evidence of
wrongdoing from the victim. In addition, many insurance policies exclude coverage for
intentional touching.
To overcome these problems, plaintiff lawyers could instead base an action on negligence
or medical malpractice. In that case, the patient will not have to show intent—only that
the wrongdoer created an unreasonable risk of bodily harm.31 Medical malpractice
depends on deviation from accepted standards. Some states set standards in their statutes
and regulations; others require expert testimony. Failure to obtain informed consent can
be considered a type of medical malpractice.
But how does a patient prove that an unauthorized exam occurred? Some prominent
teaching hospitals—including those at George Washington University, the University of
North Carolina at Chapel Hill, UCLA, and MUSC—have admitted to and defended the
practice. To survive summary judgment in a medical battery or malpractice case, a
patient need only establish through medical records that she was a patient under
anesthesia in an ob-gyn ward during the period in which the hospital admits it allowed
the practice.
This should suffice to let the plaintiff conduct discovery of hospital records to find lists of
students on the ob-gyn rotation—and other patients seen by them. Certainly, courts will
struggle with balancing the interests of public disclosure of personal medical information,
but the Health Insurance Portability and Accountability Act of 1996 provides a
mechanism to maintain confidentiality in judicial proceedings: qualified protective
orders.32
Even if students performed unauthorized exams and can be questioned, they may not
admit having done so on any given patient. Likewise, faculty members may not admit
that they directed students to do so. In addition, medical records for ob-gyn patients may
not show evidence of any teaching exam.
This failure to document educational exams—particularly when the exams are unrelated
to the reason for surgery—may be spoliation of evidence. Without recourse, the evidence
will depend on eyewitnesses and nonpatient records like operating room logs, video
surveillance of the operating room and approaching hallways, and rotation assignments
from medical schools.
Hospitals and physicians who participate in Medicare or Medicaid are required to
maintain a record of all medical procedures performed on a patient, which becomes the
patient's chart.33 Similarly, state regulations or hospital policies may require thorough
record-keeping, which could also create an enforceable right for patients or a risk of
discipline for noncomplying doctors or hospitals. If a claim of spoliation is made, the
burden could be shifted to the hospital and physicians to prove that an unauthorized exam
did not occur. A finding that the defendant concealed its activity may be sufficient to
prove actual malice and support a punitive damages award.34
Failure to obtain informed consent. In most jurisdictions, failure to obtain informed
consent is considered professional negligence. To prevail, the plaintiff must establish the
standards for disclosure and consent in the defendant's branch of medicine, any breach of
the standards, and damages proximately caused by the breach.
Establishing the duty to inform the patient of a student performing a pelvic exam on her
may seem a low hurdle. Yet, teaching hospitals are full of well-qualified, experienced,
and respected doctors who will state that no express consent is necessary for educational
pelvic exams because patients already consented to the procedures that required
anesthesia and so have impliedly consented to these exams as well.
A successful plaintiff will have to show that she would not have consented even if the
hospital or doctor had provided the missing information and that she suffered some
damage as a result. To properly frame this claim, the plaintiff must demonstrate that the
hospital and supervising physician had a duty to inform her expressly about the student
exams.
Here, the standard for disclosure varies by state. Most jurisdictions follow the
"professional" standard imposed by common law or state statutes, while a growing
minority ascribe to the "material risk" standard.35
Under the professional standard, physicians must disclose to patients what a reasonably
prudent physician would disclose in similar circumstances.36 The near-uniform failure of
hospitals and faculty to candidly disclose practice exams would seem to make it easy for
defendants to meet this standard; however, premier institutions like Harvard now require
specific patient consent for pelvic exams under anesthesia.37 Ethics guidance from the
American Medical Association also calls for specific consent,38 as do guidelines from
the AAMC and ACOG.39
Some states incorporate this ethical guidance into their medical practices act, which
governs physician conduct and makes the guidance authoritative in these jurisdictions.40
Recent reviews of ethics have also resoundingly called for specific consent.41 Thus, even
in professional-standard jurisdictions where most physicians do not disclose unauthorized
pelvic exams, plaintiffs can present evidence that a reasonably prudent physician would
do so.
In jurisdictions that follow the material risk standard for informed consent, doctors must
disclose the risks to which a person in the patient's position would "be likely to attach
significance . . . in deciding whether or not to forgo the proposed therapy."42 The
successful plaintiff will need to show that the failure to inform her of the exam violated
her right to autonomy in matters of her own body.
Because pelvic exams performed on an anesthetized patient present some risk—usually
resulting from keeping the patient anesthetized longer than she would be otherwise and
the distress of discovering that one's body was used in this way—and because the patient
receives no medical advantage from it, the risk necessarily outweighs the benefit to the
patient. Moreover, being unwittingly subjected to this risk constitutes damage itself, as
does a patient's loss of trust in her physician for not informing her of the exam
beforehand.43
One hurdle in informed-consent claims is satisfying "but for" causation. The same studies
that the plaintiff may use to help establish that unauthorized pelvic exams occur also
demonstrate that many women consent to such exams if asked before surgery. It would
seem that the successful plaintiff needs to establish that she and other reasonable patients
would have refused the exam if candidly informed.
One solution to this dilemma would be to show that the plaintiff—and other reasonable
patients—would have selected a nonteaching hospital had they been told that students
would practice performing pelvic exams on them. This may be problematic, however,
because not all women have a nonteaching hospital option nearby, especially if they are
poor or without insurance. Not coincidentally, a disproportionate share of unauthorized
pelvic exams are performed on such disenfranchised patients who cannot readily
complain.44
Breach of fiduciary duty. Few fiduciaries enjoy more respect or receive more trust than
doctors with their patients. Failure to obtain informed consent for a medical procedure
while the patient is under anesthesia cannot satisfy the doctor's fiduciary duty to the
patient.45 Some doctors and hospitals even mislead patients about the need for
educational exams, with some admission forms authorizing only medical treatment that is
"necessary."46
Fiduciary duty cases require a duty not to injure the plaintiff, a failure to observe the
duty, and an injury proximately resulting. The plaintiff must also show the wrongful
conduct was within the scope of the fiduciary relationship.47 Health care providers who
misrepresent a treatment's risks have been found liable for fraud and
misrepresentation.48 Fraud requires the plaintiff to prove intent and reliance, but the
fiduciary relationship between doctor and patient eliminates these requirements in a claim
for breach of fiduciary duty.
Further, where the supervising physician knows he or she will allow multiple medical
students to perform pelvic exams on the patient after she is anesthetized, the physician
might not inform the patient for fear that she will withhold consent. As a result, the
doctor tacitly represents his or her disclosure to be complete, while the patient justifiably
relies on the inadequate disclosure and signs the consent form agreeing to have the
surgery.
This misrepresentation violates the patient's right to rely without reservation on the belief
that her doctor will act only to protect her body and not expose her to unnecessary risks.
Breach of the special doctor-patient relationship in favor of other interests leads to a loss
of trust in medical professionals and can cause distress and humiliation. The patient
suffering a breach of fiduciary duty would be a strong candidate to recover both actual
and punitive damages.
Defenses
In defending this practice, hospitals and teaching faculty insist that patients have
consented, expressly or impliedly. Presumably, they would make the same argument in
litigation.
Express consent. Obviously, express consent is valid only when there is a complete
disclosure. Consider again George Washington University Hospital's admission form:
Nowhere does it mention the possibility of educational exams unrelated to the patient's
treatment.
In such forms, a single principle applies to consent for all care being disclosed: The care
provided constitutes "medical treatment" necessary for the patient's well-being.
Whatever benefit society may gain from training physicians, this admission form and
others do not inform the patient of or authorize exams that are for solely educational
purposes unrelated to the surgery.
When a student repeats an exam he or she just watched the attending physician perform,
the student's exam offers no medical benefit to the anesthetized patient and cannot be
said to be necessary. As a matter of contract law, these forms provide consideration only
for the initial, medically necessary exam, not for additional exams done for students'
benefit.
Although some consent or admission forms notify patients that students will be part of
their "care team," a person of ordinary sensibilities would understand "care" to be
synonymous with "treatment." Repeated exams performed solely to train students, which
offer no benefit to the patient and are not medically necessary, cannot be considered
treatment or care under any analysis. Consequently, the patient's consent on an admission
form without specific disclosures cannot be stretched to cover nontherapeutic pelvic
exams that confer no benefit to her and may even increase her risk.
Implied consent. The claim that patients give implied consent for training exams when
they accept care also fails under scrutiny.
Patients often select a particular hospital because they think they will receive good care
or because that is where their health plan offers the best reimbursement for treatment.
Some patients simply show up at the facility designated by their physician and may not
even know that it is a teaching facility or that their doctor also teaches. One study reports
that most elderly patients are unaware of a facility's teaching status.49 Some patients are
simply taken to a hospital in an emergency and may even be unconscious at the time.
In fact, there is little reason that patients should know. Disclosure to the public of a
hospital's teaching mission varies widely. A small fraction indicate their affiliation with a
university in their name, but this is far from the norm. Of the 353 members of the Council
of Teaching Hospitals and Health Systems, only 75—or roughly 1 in 5—contain the word
"university" in their name. Only one of Harvard Medical School's 18 affiliated hospitals
and institutions references Harvard in its name.50
The solution
A patient's right to control what happens to her body when she is most vulnerable is
protected by tort law. Doctors and hospitals refusing to affirm this right should be
exposed to significant liability.
In a trial, many female jurors may quietly wonder whether they too were subjected,
without consent, to pelvic exams during surgery, and most men on the jury may be able
to imagine it happening to their wives and daughters. It is likely that no one on the jury
will ever have had a conversation with a physician about students performing such
intimate exams on them.
Failing to ask patients for permission smacks of paternalism. It also reveals a deep
distrust of the generosity and goodwill of patients and their commitment to training the
next generation of physicians.
The solution is simple: Just ask. But recent experience has shown that meaningful and
complete hospital-by-hospital change is unlikely to come until a hospital or physician
pays a substantial award for this error in ethical judgment. We believe that day is coming
soon.
Notes
1. See, e.g., Evan Schulz, Not Rape, but Still Not Right: Hospitals Should Get Clearer
Consent Before Med Students Probe Anesthetized Women, LEGAL TIMES, Mar. 17,
2003, at 54; Avrum Goldstein, Practice vs. Privacy on Pelvic Exams: Med Students'
Training Intrusive and Needs Patient Consent, Activists Say, WASH. POST, May 10,
2003, at A1; Darin L. Passer, Medical Students Respect Their Patients, THE STATE,
July 19, 2003, available at www.thestate.com/mld/thestate/6338382.htm (last visited
Sept. 7, 2004).
2. Michael R. Albert, The Diverse and Controversial Career of Dr. George Henry Rohé
(1851-1899) 1-28 (Feb. 6, 2003) (unpublished manuscript, on file with authors).
3. Peter Ubel et al., Don't Ask, Don't Tell: A Change in Medical Student Attitudes After
Obstetrics/Gynecology Clerkships Toward Seeking Consent for Pelvic Examinations on
an Anesthetized Patient, 188 AM. J. OBSTETRICS & GYNECOLOGY 575 (2003).
4. Andrew West & Victoria Hunt, Student Soapbox: Learning Respect, 9 INT'L MED.
STUDENTS' J. 158 (2001), available at
www.studentbmj.com/back_issues/0501/life/158.html (last visited Sept. 7, 2004); Daniel
Cohen et al., Teaching Vaginal Examination, 2 THE LANCET 1375 (1988); Dean
Scheibel, Appropriating Bodies: Organ(izing) Ideology and Cultural Practices in
Medical School, 24 J. APPLIED COMM. RES. 310 (1996).
5. Am. Coll. of Obstetricians and Gynecologists Comm. on Ethics, Op. 181, Ethical
Issues in Obstetric-Gynecologic Education (Apr. 1997).
6. Press Release, American College of Obstetricians and Gynecologists, Statement of the
ACOG Committee on Ethics Regarding Ethical Implications of Pelvic Examination
Training (Apr. 25, 2003), available at
www.acog.org/from_home/publications/press_releases/nr04-25-03.cfm (last visited Sept.
7, 2004).
7. Press Release, Association of American Medical Colleges, AAMC Statement on
Patient Rights and Medical Training (June 12, 2003), available at
www.aamc.org/newsroom/pressrel/2003/030612.htm (last visited Sept. 7, 2004).
8. CAL. BUS. & PROF. CODE §2281 (2004).
9. See David Caruso, Pelvic Exams Without Consent, More Med Schools Now Ask
Patients, TALLAHASSEE DEMOCRAT, Mar. 12, 2003, at A3; Marilyn Marchione,
Medical College of Wisconsin Revises Pelvic Exam Policy, MILWAUKEE J.
SENTINEL, Mar. 13, 2003, at 3B, available at
www.jsonline.com/Alive/news/mar03/124975.asp (last visited Sept. 7, 2004).
10. Judy Foreman, Pelvic Exams Done Without Permission, BOSTON GLOBE, July 13,
2004, at E1.
11. Audrey Warren, Doctor Training Faces Scrutiny: Allowing Student Exams on the
Unconscious Raises Patients-Rights Issues, WALL ST. J. (Europe), Mar. 13, 2003, at A7.
12. Liv Osby, MUSC May Change Pelvic Exam Practice, GREENVILLE NEWS, Mar.
13, 2003, at B1.
13. Goldstein, supra note 1.
14. C. Beckmann et al., Gynaecological Teaching Associates in the 1990s, 26 MED.
EDUC. 105 (1992).
15. Daniel L. Cohen et al., Pelvic Examinations by Medical Students, 161 AM. J.
OBSTETRICS & GYNECOLOGY 1013 (1989).
16. Letter from Stanley Zinberg, Vice President, Practice Activities, ACOG, to Gere
Fulton, University of South Carolina, Center for Bioethics and Medical Humanities (Jan.
2, 2002) (on file with authors).
17. Suz Redfearn, While You Lay Sleeping, MEN'S HEALTH, Aug. 2004, at 146.
18. Karen Garloch, N.C. Schools: Pelvic Exams Not Gratuitous, CHARLOTTE
OBSERVER, Mar. 24, 3004, at 1E.
19. Scheibel, supra note 4.
20. Frank G. Lawton et al., Patient Consent for Gynaecological Examination, 44 BRIT. J.
HOSP. MED. 326 (1990).
21. Id.; Diane Magrane et al., Student Doctors and Women in Labor: Attitudes and
Expectations, 88 OBSTETRICS & GYNECOLOGY 298 (1996).
22. Liz Szabo, Medical Students Check Women Without Approval, VIRGINIAN-PILOT
(Virginia Beach, VA), Mar. 14, 2003, at 36.
23. Redfearn, supra note 17; Lawton et al., supra note 20.
24. Lawton et al., supra note 20.
25. Peter A. Ubel & Ari Silver-Isenstadt, Are Patients Willing to Participate in Medical
Education?, 11 J. CLINICAL ETHICS 230 (2000).
26. Charles Telfer Williams & Norman Frost, Ethical Considerations Surrounding First
Time Procedures: A Study and Analysis of Patient Attitudes Towards Spinal Taps by
Students, 2 KENNEDY INST. ETHICS J. 217 (1992).
27. Lawton et al., supra note 20.
28. A.D. Goldblatt, Don't Ask, Don't Tell: Practicing Minimally Invasive Resuscitation
Techniques on the Newly Dead, 25 ANNALS OF EMERGENCY MED. 86 (1995).
29. Patient Authorization Form, The George Washington University Hospital, Form 80-
010 (Mar. 2002) (on file with authors).
30. Statement of the ACOG Committee on Ethics, supra note 6.
31. See RESTATEMENT (SECOND) OF TORTS §18 (1965).
32. 45 C.F.R. §164.512(e) (2003).
33. 42 C.F.R. §482.24 (2003).
34. Moskovitz v. Mount Sinai Med. Ctr., 635 N.E.2d 331, 344 (Ohio 1994).
35. William J. Curran et al., HEALTH CARE LAW AND ETHICS 191-200 (5th ed.
1998).
36. Culbertson v. Mernitz, 602 N.E.2d 98, 101 (Ind. 1992).
37. Foreman, supra note 10.
38. Am. Med. Ass'n., Ethics Op. E-8.087, Medical Student Involvement in Patient Care
(June 2001), available at www.ama-assn.org/ama/noindex/category/11760.html; click on
"accept," then select "all" for policy categories, and enter "E-8.087" for search term (last
visited Sept. 7, 2004).
39. AAMC Statement on Patient Rights and Medical Training, supra note 7.
40. See, e.g., S.C. State Bd. of Med. Examiners v. Hedgepath, 480 S.E.2d 724 (S.C.
1997).
41. L. Lewis Wall & Douglas Brown, Ethical Issues Arising from the Performance of
Pelvic Examinations by Medical Students on Anesthetized Patients, 190 AM. J.
OBSTETRICS & GYNECOLOGY 319 (2004).
42. Canterbury v. Spence, 464 F.2d 772, 787 (D.C. Cir. 1972).
43. See Lugenbuhl v. Dowling, 701 So. 2d 447, 455 (La. 1997).
44. Beckmann et al., supra, note 14, at 107.
45. See Moore v. Regents of the Univ. of California, 793 P.2d 479, 485 (Cal. 1990).
46. Patient Authorization Form, The George Washington University Hospital, supra note
29.
47. See Korper v. Weinstein, 783 N.E.2d 877, 881 (Mass. App. Ct. 2003).
48. John P. Ludington, Annotation, Medical Malpractice Liability Based on
Misrepresentation of the Nature and Hazards of Treatment, 42 A.L.R. 4th 543 (1985).
49. D. King et al., Attitudes of Elderly Patients to Medical Students, 26 MED. EDUC.
360 (1992).
50. See Council of Teaching Hospitals and Health Systems Geographic Listing, at
www.aamc.org/members/listings/thalpha.htm (last visited Sept. 7, 2004); Harvard
Medical School Web site, www.hms.harvard.edu (last visited Sept. 7, 2004).
JOHN DUNCAN is a sole practitioner in Lexington, South Carolina. DAN LUGINBILL
is an associate with Ness, Jett & Tanner in Bamberg, South Carolina. MATTHEW
RICHARDSON is an associate with Wyche, Burgess, Freeman & Parham in Columbia,
South Carolina. ROBIN FRETWELL WILSON is a health law professor at the
University of Maryland School of Law. She can be reached at
 rwilson@law.umaryland.edu.