New technology has made medicine a dynamic field but little has altered the basic culture of the profession, the training of physicians. New law transforms
training of doctorsOne practice that may end is pelvic exams
on unconscious women without their consentBy Lyn Danninger
ldanninger@starbulletin.comThat may soon change. Physicians and hospitals are taking a hard look at some longtime components of physicians' training as a new federal privacy law takes effect April 15.
The Health Insurance Portability and Accountability Act, or HIPAA, regulates electronic transmission of patient information, medical records and their security. Other provisions are prompting a reexamination of all interactions between health-care providers and patients to protect patients' rights.
One change being considered concerns the gynecological examination of women.
The Wall Street Journal this week reported that physicians often train to do such exams on anesthetized surgery patients without their consent.
Medical students often are allowed by their training physicians to practice the exams in the operating room when the patient has not given explicit consent, researchers and doctors said. It is standard practice for a surgeon to do a pelvic exam before an operation, performed by inserting two fingers in the vagina to locate and examine the woman's ovaries. The primary physician usually does the exam first, then students may repeat the exam for training.
Recent studies questioned the practice and asked whether schools adequately teach students about patients' rights.
Not all doctors allow the practice without the patient's explicit consent. But some defended it as harmless and said asking for consent would make it more likely that patients would say no, denying students a crucial part of their training.
Such practices are more likely in large teaching institutions such as mainland county hospitals, said Dr. Neil Winn, an obstetrician/gynecologist and chief medical officer of Kapiolani Medical Center's medical specialists.
"That's generally not the way we train our students to do pelvic exams," he said. "We have volunteer patients who participate in our training knowingly and some who are reimbursed."
Students at Hawaii's teaching hospitals are part of a larger medical team involved in the patient's care. They are familiar with the patient, and the patient is familiar with them, Winn said.
"We just don't bring in a classroom full of students today. That's not happening," he said. Students are included in discussions with patients and are also involved in their care, Winn said.
If such an exam under anesthesia takes place, it would be because the student is part of the team caring for the patient. It would be covered by the pre-operative consent form signed by the patient, Winn said.
"Even a simple informed consent can be a one- or two-hour conversation. You have to itemize on the consent form all the procedures going to be done, ones that are known and ones that are contemplated," he said.
How many consents will be needed and how detailed they need to be to satisfy the new privacy legislation is not yet clear -- especially when it comes to medical student interaction with patients, Winn said.
"We are fine-tuning the process as it goes, trying to understand the new regulations and patient rights. But we want to be proactive and try and look at each situation," Winn said.
HIPAA attaches penalties to privacy violations. Patients will also have greater access to their medical records. Hospitals and doctors will also have to be more open and detailed about what kind of care is being rendered and by whom.
Dr. Richard Kasuya, director of the office of medical education at the University of Hawaii's John A. Burns School of Medicine, said all the major teaching hospitals in Hawaii have groups defining what they need to teach students and residents regarding patients' rights and privacy.
"It will go a long way to better ensure the rights of our patients and, second, to formalize the kind of training students get in terms of patients' rights and privacy," he said.
But reviewing every potential interaction between students and patients in a teaching hospital is a mammoth task, those familiar with the situation said. And some situations that have been overlooked will eventually wind up in court, Winn said.
But Winn said his group will address the issue of gynecologic exams under anesthesia.
"We'll probably deal with this one now," he said.
Centers for Medicare & Medicaid Services:
HIPAA Information