By SUSAN ADELMAN, MD
In the age of Larry Nassar, in the era of #metoo, what is a girl to think? What is a doctor to think? What are the rules these days? From the standpoint of doctor-patient relations, the fallout from the Larry Nassar case could be toxic for medical care.
First, how are doctors trained? When young people graduate from medical school and enter practice, traditionally they take the Hippocratic Oath, either as originally written, or as updated. The Oath has two salient sentences. The first is: “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing.”
The other pertinent sentence is “Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free.” Both of these promises are intended to prevent the doctor from engaging in self-serving behavior that is not in the best interests of the patient.
One more principle is taught to all medical students: “First do no harm,” often quoted in the original Latin: Primum non nocere.
It is assumed that the young doctor understands these admonitions. If not, he or she has no business practicing medicine. Then, after entering practice, if he or she is found to be in violation of these precepts it is up to the profession first to take appropriate action. All or almost all medical institutions have – or should have – mechanisms for reporting and acting on possible abuses. It goes without saying that any that do not have such protocols need to develop them, stat. Further, in every state our profession maintains very successful Physician Health Plans for dealing with treatable physicians who have psychiatric issues. For those who are not amenable to treatment, the Board of Medicine in every state is empowered to remove the license of any physician whose behavior is criminally harmful to patients. Beyond that, the legal system is the obvious place for addressing egregious and dangerous behavior.
What can we tell patients so they will feel secure the next time they visit a doctor? This is more complicated. Without medical backgrounds, they may not know exactly what constitutes appropriate practice and what does not. Some already fear doctors and misinterpret the reason for a legitimate pelvic exam. As a result, the doctor, intimidated by fear of the patient’s reaction, fears touching the pelvic area, even when it is entirely appropriate. Doctors today are required to have a third person present, but patients will remember that this did not protect young girls in the examining room of the crafty Larry Nassar. According to newspaper reports, he was able to conceal what he was doing even from a concerned parent.
So what are the rules that will make patients and doctors comfortable? The internal examination of any woman who ever has been sexually active is perfectly appropriate when performed in order to rule out or treat pathology in the gynecologic area. This exam also is performed in order to identify and document sexual abuse in a young girl of any age. To reiterate, in this case an invasive exam is done, with gloved hands and in the presence of a female observer, when a medical condition of the female genitalia is suspected or treated. There are very few indications for performing such an exam on girls who have never been sexually active. There is no indication at all for an internal exam to be performed without gloves. Note: The physician must be aware that in some cultures an internal exam is considered a violation of a girl’s virginity, thus possibly impairing her chance of marriage in the future.
Beyond the routine adult gynecologic exam, babies and young children may come to the doctor because of a diaper rash, an accident or other problems that warrant careful examination of the perineum, and sometimes it is necessary to perform visual inspection of the vagina using a small scope or speculum. Normally such examinations are performed by a pediatrician, pediatric surgeon, pediatric urologist or other qualified specialist. Whether or not to perform routine examinations on sexually active minors is another question, one that requires physicians to make a judgment call.
It is almost impossible to think of any indication for a sports doctor, orthopedic surgeon or any similar specialist to perform any internal examination on a girl of any age, unless possibly in the context of major surgery to treat serious trauma, cancer, other dramatic illness, or birth defects.
Doctors need to inform their patients in advance of their intention to perform examinations of the perineum, and they need to explain the rationale. Patients need to be reassured that when they go to a doctor they will be treated with respect. And, as the Larry Nassar case has shown us, when they suspect they are being mistreated, they should voice their concerns immediately.
If the doctor is able to explain the questioned procedure in a way that makes sense, that should be the end of it. If not, the patient or family should take the concern to the referring doctor or, if that is not feasible, to the institution that employs the doctor. The popular #metoo meme may help empower patients to do just that today.
What we must avoid is for patients to fear doctors and doctors to fear patients. If we need to put up the Hippocratic Oath in our offices, so be it. If we need to create and post our own office rules for examinations so patients can read them, so be it. If we need to take an extra moment to explain what we are doing, so be it. Patients need to be reassured that they will be safe when they visit the doctor and that their next doctor will not turn out to be another Larry Nassar.