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Considering the culture of consent in medicine

In this Stanford Medicine Unplugged piece, medical student Lauren Joseph shares her experience about obtaining consent in the medical field.

During the recent winter break, I went home and visited my yearly slew of doctors for check-ups: vision, dental, gynecology, etc. In the exam room, my new gynecologist instructed me to put my feet up in the stirrups. I had recently learned in a seminar at school that new guidelines on PAP smears suggest spacing them every three years for women at my age, and I wondered, "Do I even need a PAP smear this year?" Before I could finish calculating how long since my last PAP, though, the procedure was over. Before I could ask a question, before I could decide whether I wanted the procedure, it was done.

Of course, PAP smears are routine and important to screen for cervical cancer. I knew exactly what my doctor was doing, and in no way am I implying that she acted unprofessionally or did anything medically unsound. On the contrary, I'm making an observation about the standards of conduct in the physician-patient relationship that have been historically regarded as professional.

As a patient, it's never bothered me before to operate in this way: lay down, feet in the stirrups, relax, let the conversation distract me. However, now that I've begun practicing the physician's role of the physical exam, I see that transaction differently. My doctor had reminded me not to worry, adding, "This shouldn't cause any pain," but she never asked me if I wanted the procedure. It was assumed that I would cooperate, and I did. What transpired between me and my doctor was an implicit, rather than explicit, practice of consent.

Before medical school, in the dorms at my undergraduate university, I received formal training in the culture of explicit consent in relationships. "Yes means yes," insisted one of our resident assistants during a house meeting, "and consent is sexy." We learned that proper consent is not the absence of a "No." Instead, proper consent is permission in the form of a resounding "Yes."

Considering and practicing consent was a part of our campus culture. Every exchange, from borrowing someone's pencil to hugging a friend at a party, technically required asking for permission before engaging in the activity. At first, changing my behavior was difficult -- I was raised in a big, affectionate, Italian family in which trying to exit a family party requires 30 minutes of hugging and kissing goodbye to every baby, grandma, and neighbor. Though difficult, this change in my day-to-day practice helped me learn an explicit way of showing respect to other people. When I entered medical school, I brought with me my new understanding of explicit consent.

I now recognize that our medical training is still based on an old-school dynamic between patient and doctor. We are taught to gently assert, "I'm going to take a listen to your lungs," rather than ask, "May I...?"  We're reminded to focus on sounding less nervous and more confident. Asking permission is treated like a fleeting formality. In medicine, consent is often assumed.

In one practice patient encounter in class, the patient and the physician assessing my performance both gave me feedback that I asked my patient too often for her consent. I was told, "It's awkward when you keep saying what you're going to do. The patient knows you're going to touch them. Just do it." A reasonable person might agree with her, because medicine almost always operates in this way. In fact, my patient also nodded along to this sentiment.

I guarantee that my reviewers were right about me being awkward -- I'm new to the whole "doctor" thing -- but I can't say that I agree to ask for permission less. Medicine has a long history of paternalism and compliance, and the entire paradigm of health care delivery is shifting from that of a giver-receiver model to a new framework of shared decision-making. Every action we take in the exam room, such as the practice of asking for consent, might be our opportunity to create a partnership with our patients.

As a student, it feels like a clash of cultures. The culture I brought with me to medical school taught me to ask for permission. "Is it okay if I take notes during this visit?" "May I take a listen to your lungs?" Yet, the culture I'm encountering in my medical training encourages something entirely different. I'm not certain about which approach is better or worse -- especially given that my patient didn't like my approach -- but I am certain that this is one of the many parts of medicine that I'll question over the course of my career.

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

Lauren Joseph, LoJo, is a first-year medical student from Arcadia, California. She graduated from Stanford in 2017 and spent one year working in San Francisco before starting medical school. She is thrilled to be back at Stanford. She loves cooking, reading, running, and laughing with friends and family. 

Image by geralt

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