The culture of permission in medicine

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 my doctor and me 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. 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 OK if I take notes during this visit?” “May I take a listen to your lungs?” The culture I’m encountering in my medical training encourages something entirely different. I’m not sure about which approach is better or worse — especially given that my patient didn’t like my approach — but I am sure that this is one of the many parts of medicine that I’ll question throughout my career.

Lauren Joseph is a medical student who blogs at Scope, where this article originally appeared.

Image credit:

View 13 Comments >

Most Popular

✓ Join 150,000+ subscribers
✓ Get KevinMD's most popular stories