Recently, I made a post in Mothers in Medicine about Why I Fired My OB/GYN.
The reasons ran the gamut from a rude doctor to painful blood draws to ridiculously long waiting times for visits. But the straw that broke the camel's back happened about a year after I delivered. I was having my annual exam done by a male OB/GYN that I’d seen a few times before and liked well enough. After he finished the speculum exam and the bimanual exam, he said to me, “Now I’m going to do a rectovaginal exam.” And then two seconds later, he just DID it.
I’m sure somebody could present me with a body of literature on the importance of the rectovaginal exam. But I don’t care. He didn’t give me fair warning. He didn’t ask if it was okay. And it was certainly not something I ever expected, considering in my 15-odd years of annual exams, not one doctor ever deemed it necessary to perform. Plus he was a man.
I’m not saying I’m traumatized or anything. I’m not having recurrent nightmares over it. I wouldn’t report him. I mean, let’s be real here--rectal exams happen. But I didn’t like the way it happened, and I would never go see that doctor again. And since I hated the practice so much, it gave me the impetus to finally leave.
When I posted this to MiM, there were variable responses, but one in particular struck me from a recently retired physician:
The rectal examination is not ridiculous. It is not done just to detect rectal cancer but as a part of the overall evaluation of the pelvis. It allows a better feel of the uterus and ovaries and can detect conditions such as endometriosis in the septum between the vagina and rectum. In women who have had children, it allows an assessment of the muscular support of the pelvis, identifying defects in the muscles of the posterior pelvis.
I have found significant pelvic pathology, ranging from a pelvic kidney to ovarian tumors, during "routine pelvic exams" for women with no symptoms at all. Women with fibroids commonly have no symptoms. Serial exams can monitor for growth and direct the need for imaging.
Pap guidelines take into consideration many factors for an individual patient which result in a considerable fraction of the population who will not be well served by a five year screening interval.
In my practice, a patient coming in for her *annual* examination completely undressed, had her vital signs taken, thyroid, heart, lungs, breasts, and abdomen examined, and the pelvic exam, including the rectovaginal exam. I even did fundoscopic exams, finding some conditions justifying referral to an ophthalmologist.
The writer of this article was obviously already unhappy with her care. Her physician obviously had no idea she would object to the rectovaginal exam. Personally, I would have *expected* it to be done.
For goodness sake folks, if you do not understand a medical procedure of any kind, just ask. The gynecologist would have been happy to explain why he did the exam.
Fizzy, your "privates" were not "violated". Sheesh.
I think this is a perfect example of the difference between the way old school medicine was practiced versus now. For starters, saying "sheesh" and mocking me for having an exam performed that I did not consent for is not what I'd expect from a physician. You don't do whatever you want as a physician and say the patient can ask about it later. Hell, I ask permission before I even listen to heart and lungs!
I also maintain that the rectovaginal exam was NOT something I should have necessarily expected. But either way, I believe he should have asked.
I agree that your doc should have at least given you the chance to have a 5-second conversation before just going for it. Especially given that you hadn't seen him exclusively at your practice, so how could you be expected to know about, much less be comfortable with, his "standard practice?"
ReplyDeleteOn the other hand, I'm now intrigued about the rectovaginal exam. I've never had one. I've actually got my annual scheduled later this month so I'm going to ask my doc why she doesn't do them as part of the checkup.
Do you ask for permission before listening to heart and lungs?
ReplyDeleteWorking at gastroenterology, so I perform rectal exams frequently. However, I always ask, if it is ok, and give the patient enough time for mental preparation. Your GYN should have definitely ask/announce and WAIT for your reaction... on the other hand, I think you are slightly overreacting.
Actually, I do ask permission to listen to the heart and lungs. I ask permission anytime I lay my fingers on a patient.
DeleteShe said she did, as do I. Otherwise is could be considered assault.
DeleteI also ask all the time.
DeleteI also ask permission before I examine a patient, no matter how non-invasive the exam is. "Is it ok I if I listen to your heart and lungs?" "May I look at the mole you're concerned about?" It helps build rapport and shows respect for my patients.
DeleteI've had nearly identical thing done to me. I was shocked, and I think that perhaps it's intentional because otherwise the doc thinks you'll tense up and make it more difficult. But yes, not fun. Or right.
ReplyDeleteI think the proof is in the pudding. How you reacted - given that you are even a physician yourself - is proof that the way this physician went about things was not patient-centered. I will say that if you could find some way to tell him this you might benefit him and his future patients. The thorough retiree's response (fundoscopic exams, oh my!) was also enlightening. On my gyn/onc rotation we regularly did rectovaginal exams for the reasons Dr. Retired explained. So maybe your thorough doctor would benefit from some education in manners - but if he goes on to detect just one as symptomatic cancer in the rest of his career it will be worth it … as long as he doesn't keep scaring patients away!
ReplyDeleteAs someone commented below, it's NOT worth it to detect one asymptomatic cancer if that means hundreds or thousands of patients being frightened and stressed by incidental findings that then require million dollar work-ups, plus of course hundreds or thousands of patients who avoid going to a doctor entirely due to fear of an overly invasive exam.
DeleteI had the same thing happen to me. I had a low malignant potential tumor of the ovaries among other issues with the fallopian tubes and uterus. During surgery I had a total hysterectomy, lymph and liver biopsies, and an appendectomy (might as well, right?). A few weeks later, still with half of my staples in, I went to a oncology gyno. He asked if students could observe, sure, no problem. He then said I'm going to start the exam with the rectum and then not even 2 seconds later wham, bam, thank you ma'am. Those students learned a few cuss words that day. First and last rectovaginal exam, and no one I've seen before or after that has done one. I did leave there in tears, and promptly found another oncologist who was less mean (in addition to that shock the doc was rude since my path slides were a day behind me in the FedEx system).
ReplyDeleteGood grief. If you don't consent, it is assault. Yes, the fact you were there for an exam implies consent, but if this is not standard practice, I guess as defined by his specialty organization, then two minutes explaining WHAT and WHY he was doing would allow for somewhat informed consent.
ReplyDeleteassault, please. at that point you've already consented for a pelvic exam, and in his mind this was probably part of that initial consent. I agree it should have been re-asked. BUT, rectovaginal exams are standard procedure if the doc thinks its warranted, and any specialty organization will agree. I agree that his way with patients has a ways to go, but lets not crucify the doc for trying his best to look after her health. docs are only human. I would hope that if you became a doc, you would never make a mistake like this in your career as you care for your pts
DeleteFizzy is absolutely right to be upset by this. The retired physician's response is wrong for a number of reasons. Just because you can have "found things" by doing a procedure/exam/ test does not justify doing it. So you found a fibroid what do you do now if it is not causing any problems? Of all those masses you found how many of them turned out to be nothing and these women underwent the worry and additional testing for nothing. You found a pelvic kidney - what did you do about it? how was this person helped by that knowledge? I have found innumerable things incidentally on Ct scans done for other purposes. DOes this justify scanning everyone from head to toe?
ReplyDeleteTo the commenter who stated about finding one asymptomatic cancer making it all worthwhile you have to not just find the cancer it has to be a cancer that finding it while asymptomatic makes a difference. that is not always the case. With some very aggressive cancersit doesn't really matter how early you find it and it cna be too late. for more indolent cancerns finding it at a later stage may not make a difference either. also the person has to be healthy enough that they live long enough that the cancer would have killed them before something else. Unless all these conditions are met finding a mass on exam makes no difference.
We as physicians need to stop just doing things because that is how we were taught and really analyse everything we do for risks and benefits using the best available evidence even for something "routine".
The first time my ob/gyn did it 5 years ago, she explained it to me first and then did it. Thereafter at each annual exam she just says now I'm going to do the rectal part of the exam. I trust her implicitly though and wouldn't want it done by a doctor who I didn't feel comfortable with.
ReplyDeleteThe retired doc's response was condescending. And I think reflects how some doctors are not skilled with their bedside manner or even arrogant.
I had a corporate doctor at a required new employee physical ask if I was up to date on my best exams. I said yes, and he immediately proceeded to open my gown and examine both breasts. I felt that was nothing other than gratuitous and reported him to the company but was told I was overreacting. I was young and didn't press the issue further, but I definitely felt the guy violated me.
On a third instance a few years ago an ER CT scan showed a kidney some and a mass on my ovary. After an ultrasound, my primary care doc referred me directly to a oncologist gyn surgeon. He did a rectal exam without telling me first but I didn't mind a bit. In fact it was quicker and less uncomfortable than the ones my ob/gyn does.
The other reason I didn't mind was because he had very kindly and gently discussed with me his thoughts on the ct and us. I felt genuinely cared for and respected.
That's the big difference I think. Only go to docs who you feel respected by and comfortable with. I'm glad you didn't go back and maybe in the future you'll bail sooner when you see signs of disrespect for you or your time.
I have had exactly one rectal exam in my life, and I've been to multiple (more than 5) gynecologists and specialty gyn surgeons due to many, many issues with my reproductive organs. The only time it happened was in the ER, when my gallbladder was trying to break free, and the resident who performed it was very clear about what she was going to do and why, gave me plenty of warning, and the option to skip it.
ReplyDeleteAny doctor who says "I'm going to do this" and doesn't explain why, and doesn't wait for your okay, is a shitty human being and a worse doctor.
I'm a nursing student now and I'm being trained, over and over, to make sure that we have explicit permission from our patients before we do anything. Otherwise, as another person mentioned, it could be misconstrued or even labeled as assault.
It seems like everything I wanted to say has already been said before me but just to be clear he still should have asked for consent
ReplyDeleteI would have kicked him. Then filed with a bunch of different places to get his head where it should be and his ego back to where it belongs: elsewhere.
ReplyDeleteYou were better than me Fizzy.
There was totally no excuse for that. Ever.
Only had 8 weeks of OBGYN during med school, and never saw anyone get a rectovaginal exam. In fact, outside of the SP who taught it to us, I only ever saw it during a rectovaginal fistula takedown, and that was on an anesthetized patient, and probably warranted. But even on colorectal services, rectal exams came with almost a full informed consent. Who wouldn't want that as a patient? Who wouldn't give that as a doctor? It's an awkward situation for everyone. At least talk about it beforehand to get the apprehension out of the way.
ReplyDelete
ReplyDeleteThankfully that insensitive witch of a doc that made the comment isn't practicing anymore! "The doctor would've been happy to explain AFTER the exam!" WTH? Explain, request consent (give the patient a few seconds to process & acknowlege) & if given permission, proceed! You absolutely didn't overreact, in fact, some may argue you under 'acted' on this one!
You've certainly started a great dialogue here!
I actually had a rectal exam done by a PSYCHICIATRIST! In the hospital, with no consent! GAH!!!!!!!!!!!!!!!!!!!!
ReplyDeleteUnless they were doing a cavity search for drugs and had your consent, I don't see how this could be considered ethical. To do this to someone at their most vulnerable time just seems like an abuse of power, just like the idiot corporate doc who did a beast exam on me... only worse.
DeleteT was stunned, absolutely stunned and had no idea what to do at the time!
DeleteNeedless to say, he was a Bastard!
ReplyDeleteHe was a dick. I at least say "excuse me" before I place a hand or my stethoscope on my patients, and any procedure which requires me inserting my fingers or any type of device into someone is first explained, justified and asked about. You can't just shove your finger up someones ass without their express consent because you're a doctor.
ReplyDeleteAlthough it may have been startling, I think you are overreacting. He DID say he was going to perform the rectovaginal exam and proceeded to do so- I'm sure he figured he didn't need to explain why to a physician. FFS, some of the other commenters are hypersensitive or just very uncomfortable with exams!
ReplyDeleteI've never had a rectovaginal exam. I've been to several OB/GYNs over the years, and not once has any one of them shoved a finger up my posterior. Not once. Not during either of my pregnancies, not before, and not after. I wasn't even aware that they *might* do that.
ReplyDeleteI had one Doc that thought using 4 fingers on me during the normal pelvic exam was a-okay. (I'm pretty sure he was checking my tonsils.) After he did that I suggested he invest in shoulder gloves, like the ones vets use for inseminating cows. But even that guy didn't stick his fingers in my rear.