I apologize in advance that this story is a little bit TMI. Then again, I live in a world where about a third of the time, a cat or a child comes into the room to watch me pee, so nothing is really TMI anymore.
When I moved to a new town and found myself newly pregnant, I knew I had to find an OB/GYN practice. So I basically googled “OB/GYN” and picked a large nearby practice that popped up and selected a doctor with decent reviews. My first visit was pretty good, and I decided to stick with the practice.
Unfortunately, things went downhill. The worst thing was the wait. I’d come in for increasingly frequent pregnancy checks and end up waiting an hour for my five-minute visit. The most aggravating visit occurred when they called me to come in early because they were running ahead. I dropped everything at work to show up early, and STILL waited thirty minutes, until the time of my original appointment.
Also, they did the worst blood draws ever there. Any time they needed blood, I would end up with bruises all over my arm and severe pain for days. When I objected to doing the glucose tolerance test there for that reason, I felt like I was treated like a criminal by the staff and the very un-understanding OB/GYN.
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.
(And my current practice has never made me wait more than five minutes.)
I do have to say, if you’re a male doctor, I think you do need to be careful about that sort of thing. You can’t just go around sticking your fingers wherever you like without warning your patients. Not that I can do that as a female doctor, but I think there is a little more wiggle room. (Literally and figuratively.)
When I did a family practice rotation at an ancillary site in small town, the male OB made me do rectovaginal exams on all the female patients. It made me feel really uncomfortable because I never learned/did any of this at large training institution, but I didn't mention it just did it and got through it. He was much older - made me wonder if it was something they did in the past. Was your OB older?
ReplyDeleteBy the way I switched OB's too before I had kids. The OB I had since I was a teenager told me I had vaginal warts and needed laser. I insisted that it was practically impossible based on my history but she told me I was wrong - this was before I started med school so I wasn't very medically informed. When I went back to get them lasered off she said she has no idea what she was thinking I did not have warts (no HPV PCR testing back then I guess? This was all visual). I was so freaked out I never went back. There's some TMI back atcha:)
He was maybe in his 50s, but I don't think he was born in this country. Maybe that was the difference?
DeleteI was trained to do rectovaginal exams to accurately locate the uterus. When I started doing office gyn a few years later, I looked it up and there didn't seem to be any evidence, so I stopped doing them. And yes, of course, ASK. And wait. Good God.
ReplyDeleteA friend of mine wrote to ask me about an encounter she had with a pulmonologist. On the first visit, he did a breast exam. She has a PCP and a gynecologist and is up-to-date on her screening. He didn't ask, he just did it. On the second visit, he unhooked her bra - again without asking - while he auscultated her lungs. She said "Am I being too picky?" I said NO. Good God, again.
I'm actually surprised that more people aren't telling stories about their private areas being violated...
DeleteMany years ago when I was in college I went in for a routine exam at a University clinic. It was all normal and the nice young doctor had the speculum in my vagina, until I started feeling some pain. What's that, I asked? He said, I'll tell you later. After I sat up, he said that there was a little endometriosis and he had just burned it off. Ok, I said, and then started hyperventilating. I was not in touch with my feelings in those days. It took me many years before I went to a doctor again.
ReplyDeleteThe one year I didn't have a rectal exam during my annual exam was the year I was diagnosed with Stage III rectal cancer. The surgeon identified it as an aggressive SCC that took about 15 months to reach 7.5 cm. I became a believer in annual rectal exams!
ReplyDeleteTrained in the U.K. taught always perform a rectal exam at least annually. Caught several carcinomas. However bedside manner is essential!!
ReplyDeleteHowever, you have to wonder how many patients are scared away from seeing a doctor by the idea of having a rectal exam, and if loss of primary care for many hundreds of patients is worse catching a few carcinomas in a lifetime.
DeleteI was taught rectals in all women over 35 at the begining of Med school, but then I think the guidelines changed. Now they are a lot more parsimonious about who even gets a pelvic I think.
ReplyDeleteI was under 35 at the time.
DeleteI am an academic family physician, and this is ridiculous. There is absolutely no evidence that a rectal exam in either gender is necessary or changes medical outcomes if the patient has no symptoms. The pulmonary physician who did a breast exam should probably be reported. Routine pelvic exams have no evidence for changing outcomes, and guidelines now recommend Paps every 3 to 5 years depending on your age and HPV findings. It's not parsimony, it's science. Of course doctors will run behind who are performing outdated unnecessary exams, but not asking you about your alcohol intake and sleep patterns and depression and dozens of other issues that will shorten your life. Thank you, I will now step off my soapbox.
ReplyDelete^^ all of this x 1,000.
DeleteHe was reported, at my urging.
DeleteTotally agree with you smz.
DeleteTotally agree with you smz.
Delete@ smz: I am a retired gynecologist, not an academic, just one who retired after a few decades of taking care of women in a community office setting.
ReplyDeleteThe 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.
smz, do your patients undress for their exams or do you listen to heart and lungs through clothing?
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.
Oh, and yes I did take a social history.
I never said my privates were violated....
DeleteIt should be said that I have had at least 20 annual exams in my lifetime, done by over 10 physicians (I've moved a lot), including two of that physician's colleagues. Other than that one guy, not ONE of those physicians did a rectal exam. Were they wrong? Possibly that's up for debate. But if he didn't realize I'd be caught off guard by him doing that, then he has absolutely no clue about common practices for OB/GYNs. Which is troubling in itself.
Him saying "would that be OK?" would have made a big difference. Hell, I do that when I just do a heart/lung exam.
No consent = assault. No patient should ever expect to be touched on their breasts/chest/genitals, least of all penetrated without affirmative consent.
DeleteNo consent = assault. No patient should ever expect to be touched on their breasts/chest/genitals, least of all penetrated without affirmative consent.
Delete>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.
DeleteInternist here - one who runs a med school course on the physical exam. Of those exam maneuvers you've listed, exactly 3 have a place in the routine examination of healthy patients without symptoms: BP and BMI assessment, and (depending upon age and history) Pap smear. Everything else is, at best, an inappropriate use of yours and patient's time. At worse, some of these are potentially dangerous by uncovering "findings" which don't represent pathology, but will trigger additional unnecessary and increasingly invasive testing with much higher rates of false positives than true positives.
Yeah, and that includes a "routine" rectal exam, in both genders.
A good summary reference: http://www.ncbi.nlm.nih.gov/books/NBK82767/
Sheesh I'm glad that Suzanne has retired - no patient should have to undergo an intimate exam (or be touched for any reason really) without asking the patient and clearly defining what will happen during the exam. It doesn't matter what you think the patient should "expect" - that is paternalism and not how a theraptuetic relationship is practiced.
ReplyDeleteFizzy, thanks SO much for posting your experience. This has obviously opened up the topic for conversation. I'm IM, and was doing annual pelvic exams on everyone until enough research was published to officially change the guidelines (2014, link here: https://www.acponline.org/acp-newsroom/american-college-of-physicians-recommends-against-screening-pelvic-examination-in-adult-asymptomatic). Now, because the accumulated data shows little to no benefit to this exam in asymptomatic patients, I can't justify performing one if there are no symptoms. Yes, ACOG (OB/GYN) still recommends annual screening pelvic exams in women over the age of 21, but even they are very clear in their published guidelines that this recommendation is NOT based on data, and is only based on "expert opinion": http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Well-Woman-Visit . And rectovaginal exams? Even ACOG states those should only be performed when indicated. Fizzy, a whole other debate is if any provider performing an invasive exam should have a chaperone. Alot, alot of docs are using chaperones... What do folks think, do we not only need to have consent for invasive exams, should we also have chaperones? For pelvic/ rectal exams, or for breast exams as well?
ReplyDeleteI haven't done primary care since 2009. I did not use a chaperone for breast exams; I did have a staff member in the room for pelvics as an assistant. Our rooms weren't really set up for GYN exams (I'm IM) and it helped to have an extra set of hands. I always wondered about a chaperone for hernia checks, testicular exams and rectals on men, but never did it.
DeleteI think they're very well might have been a chaperone in the room for the exam. It didn't change the fact that he was not appropriate.
DeleteI remember a male OB/GYN once asked me if it would be OK if he did not use a chaperone, because there wasn't one available. My feeling was that it was as much for his protection as for mine.