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WOWR: Anonymous Dr.'s response to transvaginal ultrasounds
http://whatever.scalzi.com/2012/03/20/guest-post-a-doctor-on-transvaginal-ultrasounds/
Guest Post: A Doctor on Transvaginal Ultrasounds
A friend of mine is a physician who wants to speak about transvaginal ultrasounds but whose position makes it precarious to speak publicly about it. So I?m letting this doctor borrow my site for an entry to speak anonymously on the matter. Obviously, I will vouch for the doctor being a doctor and being qualified to speak on the subject.
?
Where Is The Physician Outrage?
Right. Here.
I?m speaking, of course, about the required-transvaginal-ultrasound thing that seems to be the flavor-of-the-month in politics.
I do not care what your personal politics are. I think we can all agree that my right to swing my fist ends where your face begins.
I do not feel that it is reactionary or even inaccurate to describe an unwanted, non-indicated transvaginal ultrasound as ?rape?. If I insert ANY object into ANY orifice without informed consent, it is rape. And coercion of any kind negates consent, informed or otherwise.
In all of the discussion and all of the outrage and all of the Doonesbury comics, I find it interesting that we physicians are relatively silent.
After all, it?s our hands that will supposedly be used to insert medical equipment (tools of HEALING, for the sake of all that is good and holy) into the vaginas of coerced women.
Fellow physicians, once again we are being used as tools to screw people over. This time, it?s the politicians who want to use us to implement their morally reprehensible legislation. They want to use our ultrasound machines to invade women?s bodies, and they want our hands to be at the controls. Coerced and invaded women, you have a problem with that? Blame us evil doctors. We are such deliciously silent scapegoats.
It is our responsibility, as always, to protect our patients from things that would harm them. Therefore, as physicians, it is our duty to refuse to perform a medical procedure that is not medically indicated. Any medical procedure. Whatever the pseudo-justification.
It?s time for a little old-fashioned civil disobedience.
Here are a few steps we can take as physicians to protect our patients from legislation such as this.
1) Just don?t comply. No matter how much our autonomy as physicians has been eroded, we still have control of what our hands do and do not do with a transvaginal ultrasound wand. If this legislation is completely ignored by the people who are supposed to implement it, it will soon be worth less than the paper it is written on.
2) Reinforce patient autonomy. It does not matter what a politician says. A woman is in charge of determining what does and what does not go into her body. If she WANTS a transvaginal ultrasound, fine. If it?s medically indicated, fine? have that discussion with her. We have informed consent for a reason. If she has to be forced to get a transvaginal ultrasound through coercion or overly impassioned argument or implied threats of withdrawal of care, that is NOT FINE.
Our position is to recommend medically-indicated tests and treatments that have a favorable benefit-to-harm ratio? and it is up to the patient to decide what she will and will not allow. Period. Politicians do not have any role in this process. NO ONE has a role in this process but the patient and her physician. If anyone tries to get in the way of that, it is our duty to run interference.
3) If you are forced to document a non-indicated transvaginal ultrasound because of this legislation, document that the patient refused the procedure or that it was not medically indicated. (Because both of those are true.) Hell, document that you attempted but the patient kicked you in the nose, if you have to.
4) If you are forced to enter an image of the ultrasound itself into the patient chart, ultrasound the bedsheets and enter that picture with a comment of ?poor acoustic window?. If you?re really gutsy, enter a comment of ?poor acoustic window?plus, I?m not a rapist.? (I was going to propose repeatedly entering a single identical image in affected patient?s charts nationwide, as a recognizable visual protest?but I don?t have an ultrasound image that I own to the point that I could offer it for that purpose.)
5) Do anything else you can think of to protect your patients and the integrity of the medical profession. IN THAT ORDER. We already know how vulnerable patients can be; we invisibly protect them on a daily basis from all kinds of dangers inside and outside of the hospital. Their safety is our responsibility, and we practically kill ourselves to ensure it at all costs. But it?s also our responsibility to guard the practice of medicine from people who would hijack our tools of healing for their own political or monetary gain.
In recent years, we have been abject failures in this responsibility, and untold numbers of people have gleefully taken advantage of that. Silently allowing a politician to manipulate our medical decision-making for the purposes of an ideological goal erodes any tiny scrap of trust we might have left.
It comes down to this: When the community has failed a patient by voting an ideologue into office?When the ideologue has failed the patient by writing legislation in his own interest instead of in the patient?s?When the legislative system has failed the patient by allowing the legislation to be considered? When the government has failed the patient by allowing something like this to be signed into law? We as physicians cannot and must not fail our patients by ducking our heads and meekly doing as we?re told.
Because we are their last line of defense.
Re: WOWR: Anonymous Dr.'s response to transvaginal ultrasounds
and when the unborn are revered more than the women...
I'm not in the business of defending these laws, but
If I insert ANY object into ANY orifice without informed consent, it is rape. And coercion of any kind negates consent, informed or otherwise.
by this definition, would requiring me to have a pap smear to get a BC prescription also be rape? Both coerce by denying access to a medical procedure I need/want unless I submit.
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Thank you for posting this.
I've been wondering when doctors would begin pushing back from being used as political pawns.
No. It's medically necessary which the doctor makes allowances for in his statement. A pap is necessary to determine if you can safely go on BC.
If being pregnant has taught me anything it's that no procedure can be performed on you without your consent. You can refuse a pap smear. But then it's up to the doctor to decide if he or she is comfortable prescribing BC to you w/out it. The pap smear isn't to shame the woman into not getting BC the way the vaginal wand is to shame a women into not having an abortion.
I don't believe the law requires you to get a pap smear in order to get a rx. I believe that's just what most dr's want and do. Also, you have alternative non prescription (albeit less effective) bc options.
In the case of an alternative to an abortion, there isn't one for someone who actually wants one.
Actually, one is denying you access to a medical procedure unless you submit.
The other is denying a prescription until you undergo a medical procedure that verifies that you're healthy enough for the prescription.
Now, you can argue the validity of the latter all you want. And, in fact, IIRC they JUST changed the recommendations from having a pap annually to every 2 years.
But the comparison is not apt.
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It is similar, but I suppose doctors would argue that the Pap is medically indicated (even though the recommendation is every two years now, yes?).
I'm actually dealing with this now, my doctor refuses to even write me a bridge prescription until I come in. But I can't come in until April. So I've been off the pill for a month now.
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I think something that's gotten lost in all of this fuuckery is that doctors are still occasionally going to have to do transvaginal ultrasounds, because they're sometimes going to be indicated.
The problem with this bill is that the GOVERNMENT is telling doctors how they should practice medicine. The GOVERNMENT is requiring a procedure, even when an individual doctor and the medical community find it unnecessary.
Whether or not a transvaginal ultrasound is necessary before an abortion is performed in a specific case is a decision that should be made by a patient's doctor, NOT the government. And if a transvaginal ultrasound is necessary, the doctor should be required to get informed consent from the patient before proceeding.
Allowing the government to step in and dictate that doctors practice unnecessary medical practices is what's wrong with this bill, not the practice of transvaginal ultrasounds themselves.
"You don't get to be all puke-face about your kid shooting your undead baby daddy when all you had to do was KEEP HIM IN THE FLUCKING HOUSE, LORI!" - doctorwho
Also, a pap and/or pelvic are not even necessary to safely get a rx for bcp's.
I think linking them, however, stemmed from the idea that annual exams are important preventive care for screening for cancer and reproductive system problems and it's easier to do it all in one shot.
I actually think linking them decreases usage b/c 1. many women don't want to get the internal exam and 2. might not have the funds/insurance.
Again, putting aside the question of what the law requires, because I agree that's a distinction here.
It is my understanding that ultrasounds are frequently indicated (by doctors, not legislators) before abortions are performed to make sure the pregnancy isn't ectopic, etc. and thus the abortion is safe to perform. Is that not correct?
If a doctor won't perform an abortion without a transvaginal ultrasound for safety reasons, is that doctor then raping that patient? My understanding from the OP is that he would say yes.
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That's not what I got from the OP at all. I don't have it open in front of me, but IIRC, he said that IF a transvaginal ultrasound was indicated, then the doctor would be required to speak with the patient about it, and informed consent would be required.
"You don't get to be all puke-face about your kid shooting your undead baby daddy when all you had to do was KEEP HIM IN THE FLUCKING HOUSE, LORI!" - doctorwho
In the quote, he says if you're "coercing" someone - as in denying them treatment unless they do it - then there's no such thing as informed consent.
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My info re: Ultrasounds (including transvaginal ones early in pregnancy) being a standard part of abortion care comes from here:
http://www.slate.com/articles/double_x/doublex/2012/02/transvaginal_ultrasounds_why_pro_choice_advocates_shouldn_t_call_them_rape_.html
and here (under "what happens during an in-clinic abortion"):
http://www.plannedparenthood.org/health-topics/abortion/in-clinic-abortion-procedures-4359.asp
Again, not advocating for laws here. Just saying I think spreading the message that a doctor who insists on doing these things for safety reasons is a rapist is a little strong. I still don't understand how it's any different from a doctor insisting on doing a pap (again, for safety reasons) before prescribing BCPs.
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So what safe alternative to an abortion is there to remove an unwanted fetus?
The issue with the laws, in the case of the VA law, for instance, is that it was mandatory no matter what. There was no informed consent. Neither the woman nor the doctor could opt out. That law was scrapped in favor of a mandated external ultrasound.
I don't think I understand the question. Presumably if an ultrasound showed some reason a traditional abortion would be unsafe, there's some other procedure to perform--I'm certainly not an expert.
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They do it because it's good medical practice. It's more comparable to asking for a termination and having no idea about your dates. If the doctor can't date the pregnancy they might want to do an ultrasound to determine if you can have a medical termination, and if not that, then what sort of procedure you need.
If the ultrasound is medically indicated, presumably the doctor will explain why to the patient and get their consent (which the woman would presumably give when provided with a medical reason). The argument here is about the procedure as a legal requirement for abortion, even if the doctor feels there is no medical indication for it.
Now I'm getting confused. But here's what I've got.
When a doc chooses to use a ultrasound before an abortion it's typically to date the pregnancy. They can then help the woman choose the method of abortion - early abortions can be done with things like RU-486 or by D&E (surgical abortion).
When a doc is mandated to do an abortion by law, it's mostly required by legislators to make sure the woman knows what she's doing, to make her feel bad, and/or to change her mind.
From my understanding it is very rare that a trans-vag u/s needs to be used to date a pregnancy. A regular over the belly u/s is usually enough.
A medical termination - RU-486.
i think the issue lies not in the fact that an u/s is being performed but rather the type of u/s. a transvag u/s is way invasive.
IIRC, other states require the woman to watch the u/s to see what is going on. they may not mandate the method but they do require you to actually watch it.
both of these go beyond the base requirement for medical treatment, which is what makes them both completely screwed up.
You are trying to show there isn't a difference between "Coercion" between a doc requiring a pap to get BC and the govt requiring the doc to perform a transvaginal ultrasound to perform an abortion.
If the patient doesn't want the pap that a doc believes is required, then the patient has many other opions for BC.
So if they aren't different, then what other safe options are there beyond a medical abortion does the patient have if they don't want a transvaginal ultrasound that the doc doesn't believe is required to abort a fetus but the govt does?
Ahh with you now. Not sure I like the argument though--are you saying doctors shouldn't be able to require a medical test to provide a procedure or prescription, if the patient doesn't have an alternative? So like if BCPs were the only form of contraception, you couldn't require a pap smear then?
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If you?re really gutsy, enter a comment of ?poor acoustic window?plus, I?m not a rapist.?
This is just about the best thing I've read all day.
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No, I'm saying that a doctor requiring a patient to have a test they doctor believes is necessary is not coersion. As the patient, if you don't want to have the test done, don't. The patient has other safe options for birth control beyond the prescription the doctor is refusing. There is no threat to the patient that they can not have safe birth control if they refuse and there is no threat to the doctor for refusing a prescription.
The govt requiring a doctor to do a procedure before providing a medical procedure, with no regard to whether the doctor believes it is a medical necessary or not, and when there is no other safe alternative for the patient to remove the fetus, then that is coersion. Here, there is a threat to the patient that they can not have a safe removal of the fetus if they refuse and there is a threat to the doctor if they refuse to perform the govt-mandated, medically uneeded procedure.
Ok, but if the doctor requires an ultrasound in order to have an abortion and the patient doesn't want one so the doctor refuses to perform the abortion, is that ok in your mind? Both are the doctor laying out what he/she deems medically necessary, but in the case of the abortion the patient presumably doesn't have alternatives like they do for BC. Does the availability of alternatives matter?
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