Not that long ago, I was discussing with a group of physicians why I support the use of scribes in the medical office. It decreases the documentation burden on physicians. Scribes, in person or virtual, allow clinicians to look patients in the face. And in-person scribes help to reduce patient nervousness about being alone in a room with a physician.
The lead physician in this small, all-male physician group meeting with their female administrative staff and me (the consultant) was incredulous at my last statement. How could any patient, female or male, be uncomfortable by being alone with a healthcare professional?
Enter the elephant in the room. Many physicians, especially those trained before the turn of the century, are unaware of one simple fact: even though the patient has walked into an exam room, and may even have requested to have a female practitioner, that does not mean that you have informed consent to touch the patient.
To gain the perspective of my clinician colleagues -- I consider the fact that a patient walks into an examination room to be inferred consent for physical contact. Yes, from the fact that the patient is there in a room, it is reasonable to infer consent. Yet, the consent is for diagnosis and treatment. Patients are unaware of HOW clinicians are going to gain the knowledge for adequate diagnosis and treatment. Therefore, simply explaining to the patient what is going to happen next, and asking their permission to do so, is informed consent.
The following scenario happened to me in an exam room for my annual physical. I know my clinician well and we had a long discussion about consent after this encounter:
I walk into the exam room and sit down on the exam table.
The medical assistant (MA) comes in and says she is going to take my vitals.
She pulls the blood pressure cuff off the wall. I consent to this contact by rolling up my sleeve and sticking out my right arm. She writes down the numbers (but doesn't tell me what they are).
She grabs the digital thermometer base. Sleeves the thermometer and asks me to open my mouth. I consent to this contact by opening my mouth. She writes down my temperature (but doesn't tell me what it is).
She escorts me to the scale and I reluctantly (because I don't want to see how much weight I've gained) stand on the scale. I see what the scale says ... and she dutifully writes down that I'm now overweight.
The MA thanks me and says that my clinician will be in soon. I pull out my cell phone and play my daily challenge at solitaire.
In walks my clinician. I end my solitaire distraction, and we catch up on all the recent life events, including past and upcoming vacations and our husbands equally driving us nuts. Finally, she opens up her laptop and begins asking questions for the physical.
After those questions are answered, she puts her laptop away and stands up. She gets to the examination table facing me, and while chatting, puts on her stethoscope. She places the stethoscope on my upper chest and asks me to take a deep breath. I take a dramatic breath and remind her of one of our past conversations: "You didn't ask me for consent to touch my person." She steps back and takes a breath. "Right. You're right. I totally forgot."
So, what should have happened? What should have happened is: "I'm now going to listen to your lungs and heart by placing this stethoscope on your chest and back. Is it okay if I continue with this examination?" Then give the patient time to nod or indicate in the affirmative before proceeding.
It amazes me that clinicians are trained that for certain types of physical examinations, namely breast and pelvic exams, that they explain what they are going to do and if the patient consents to the examination. But this simple act of good medical practice isn't commonly done for any other type of physical contact.
Over the course of my career, as a patient and while shadowing duly licensed practitioners, I've seen a range of conduct with patients, which almost always never affirmed patient consent.
I've seen very nervous patients who are clearly huddling on the back of the examination table be chased by a clinician simply focused on getting the physical examination done as quickly as possible to move onto the next patient.
I don't believe this action was malicious or malpractice. Physicians and other medical professionals are focused on the never-ending cycle of patients through the exam rooms and are not picking up on the social cues right in front of them.
Further, I believe that the patriarchal medical school and continuing medical education environment has failed to reinforce the importance and necessity of patient consent.
The industry has focused on the general concept of informed consent -- the concept that the patient understands the course of treatment and the risks associated with it. But this is more a function of limiting malpractice liability rather than ensuring that the patient truly appreciates what is being done to them, how it is being done, who is involved in the course of treatment, and possible outcomes.
Let me give you a personal example: my husband and I went through the trials of fertility treatment several years ago. As we prepared for the procedure to remove what we hoped were follicles (but were just cysts), I -- as a patient who reads everything; a super-duper informed, clinically aware, and health-literate patient -- learned by reading a poster on the wall with illustrations that my egg retrieval procedure was going to insert a needle through my vaginal wall into my ovary. How did I miss this? I had to have signed a document that stated something about the nature of the procedure. I doubt I would have consented to egg retrieval if I had known the surgical approach for retrieval.
A couple of observations: I did go back and check. I signed a generic consent to fertility treatment statement that said something along the lines that I understood the procedure and risks for egg retrieval. It didn't tell me how that egg retrieval was done. It did not include any explanation of the procedure approach. I somehow thought they went in through the abdomen to suck out the follicle. Boy, was I wrong!
An observation from one of my former colleagues while at UnitedHealth networks, Mike O'Boyle, is very apt. "Jen," he told me, "we can educate beneficiaries all we want. They won't remember anything when they become patients."
He's right. In my focus to have a baby and the heartache, lack of sleep, and craze of fertility drugs and hormones, I wasn't paying attention to what was being done to my body. I made more effort to find the cheapest source of the fertility drugs (just imagine me on that hunt) than to understand what medical procedure was being done to retrieve my eggs.
Here's my advice to clinicians practicing today: tell patients of all genders what you are going to do in your examination and simply ask the patient if they consent to being touched. It is a new habit that needs to be an integral part of the American ethos of consent.
Imagine how young men (and women) will respond to life in general, if their own physician begins to ask them if they consent to be touched.
Jennifer Searfoss, JD, is founder and CEO of , a healthcare consulting company in Winchester, Virginia. This post originally appeared on .