One More Pelvic Exam

Janet Chin, a third-year medical student, has just begun a clerkship in obstetrics and gynecology. For this six-week rotation she is assigned to work in clinics and on wards of a large public hospital that is affiliated with the medical school. She is especially looking forward to the work because ob-gyn is one of the specialties she is considering for a career. During her second year, Janet received some instruction in how to do a pelvic exam, but she realizes that she needs more experience to become adept at this important part of the gynecological examination. On the second day of her clerkship, she is presented with an opportunity to gain some experience. She is one of three students who is assigned to work two mornings a week with an attending physician whose practice includes gynecological surgery. She and the other two students scrubbed in for a case of a patient scheduled for surgery because of fibroids of the uterus. While the patient was under general anesthesia, the attending physician did a pelvic exam and explained to the students what he felt. He then said that this was the ideal time for students to do a pelvic exam: the woman would feel no discomfort, the students would discern much more than usual because the muscles are relaxed under anesthesia, and everyone would confirm an important finding. The attending physician then motioned to the first student to step up to examine the patient. When the first student was done, the second student took his turn. When he finished, Janet would have to decide whether to take her turn or decline. Although she wanted very much to gain the experience, she still hesitated. In the minute she had to decide, conflicting thoughts rushed through her mind. "Are three extra exams too many? Did the patient consent to multiple exams? What would I think if I were the patient? Would we be doing this at the school's from hospital? How will I learn if I decline these opportunities? Won't future patients benefit from my learning things now?" What should Janet do? COMMENTARY by James Dwyer To clarify the problem in this case, it is helpful to consider two extreme views of learning on and from patients. One view is to regard patients primarily as learning material and to treat them primarily as a means. This view is uncaring and dehumanizing. The other view is to insist that no patient be subjected to multiple examinations or to procedures done by people who are not already very skillful and experienced. This view is absurd; it would bring the learning of medicine to a halt. Between these two extremes is a morally sensible view: learning on and from patients may proceed but should be done in a way that cares for their well-being, respects them as persons, and is just. Since there is a tendency to focus too little attention on the social arrangements in which ethical problems arise, I want to begin with the question of justice. Future patients may benefit from what Janet Chin learns now, but her future patients may be of a different social class from her present patients. Students and residents who learn on poor and working-class patients at public hospitals often go on to establish private practices that serve middle- and upper-class patients. Although many medical schools have affiliations with private as well as public hospitals, students and residents do more hands-on learning at public hospitals and clinics. Thus in general, public patients bear more of the disadvantages associated with people learning to practice medicine: more risk and discomfort, less convenience and privacy. In defense of the present arrangement, it is often said that students and residents who work at public hospitals are providing care for people who would otherwise lack access. But that the present arrangement is better than letting people go without care does not show that it is justified. All people should have access to care, and I cannot think of any good moral reason for subjecting poor and working-class patients to more risk, discomfort, and intrusions. …