SSSFELICIANO’S MAR [15-03]:Internal Examination: To Do or Not To Do for Surgeons

Indexing Title: SSSFELICIANO’S MAR [15-03]
MAR Title: Internal Examination: To Do or Not To Do for Surgeons
Date of Medical Observation: March 2015
Tag: An issue of whether surgeons be allowed to do other maneuvers of another specialization
Category: Professional/Ethical – Stimulus
I was paving my way down the stairs when I received a call from my junior manning the Emergency Room. He was referring a 30-year-old female to me who was allegedly complaining of hypogastric pain with no associated symptoms. Physical examination of the abdomen was unremarkable. However, upon digital rectal examination, there was note of an extraluminal mass. Suspecting a gynecologic pathology, consent for an internal examination was asked for and upon doing it, a mass was palpated, probably from the cervix. Upon arriving at the Emergency Room, I too, did my history and physical examination with same findings, hence, I advised referral to the OB-Gyne Department. To my surprise, the intern who referred the patient told me that the OB resident was questioning our diagnosis for the patient and was asking why we did an internal examination. Allegedly, there is a protocol that only OB residents are allowed to do an internal examination. Alarmed with this, I called the attention of the OB resident and asked her of the protocol stating that we are not allowed to do an internal examination of patients for whom we are suspecting gynecologic pathology. Unfortunately, I was only able to talk to the junior resident since the senior was attending to a patient and she could not present to me the protocol. I explained to her that I was just doing a complete physical examination of the patient that’s why I did the internal examination, and that I am not aware of any protocol stating that we are not allowed to do it. She promised me to present the protocol but failed to do so. I consulted advice from the ER officer and told me that he is not aware of such protocol, too, and that what we did was right. The patient was seen by the OB Department and was eventually transferred to their service. Up until now, there was no protocol presented to me.
Insight: (Physical, Psychosocial, Professional/Ethical) (Discovery, Stimulus, Reinforcement)
The practice of Medicine has always been segregated into different specializations or fields of interest. This was done so that physicians are given the opportunity to focus their craft to a certain field therefore delivering better quality health care to particular needs of patients. Unfortunately, this also causes some doctors to be boxed in their specific chosen fields. Inadvertently, these doctors become less well-rounded, and their thinking and practice is limited to their area of expertise. From the beginning of our medical training in school, we were taught all basic physical examination maneuvers without being limited to procedures, examinations, and assessment tools that are peculiar to certain specializations. We are all educated with the same knowledge and imparted with similar skill sets before we decide to take on a more dedicated path in our practice of medicine. With this in mind, what could limit us to do a physical examination that can help us get closer to the correct diagnosis therefore ensuring proper patient care?
It is supposed to be a non-issue that practitioners of one specialization be able to do the basic physical exam of another specific specialization. A specialist performing a maneuver of another specialization should be welcomed as a gesture of goodwill towards the patient and not as an infringement of practice of another department. This can be applied in our situation wherein performing the internal examination for the complete assessment of the patient was needed. For me, a specialist who is able to think outside the confines of his chosen specialization is considered to be a better doctor than a specialist who is well-versed only in their specific department. High quality health care is delivered through well-roundedness and competency and not just through specialization-limited thinking and practice. It therefore came to me, that an action be further taken to clarify the issue of us surgeons, doing internal examination for our patients whom we consider to have a gynecologic pathology. This is not to downgrade the role of the gynecologists of this institution, but to teach not only ourselves but our colleagues the practice of doing a complete assessment of the patient for quality patient care. 
ROJoson’s Notes (16sept20):
Yes, it is a non-issue that practitioners of one specialization be able to do the basic physical examination of another specific specialization. There should be no turfing among the specialists when it comes to basic physical examination. The latter is actually expected of all physicians.  The only time that a physician does not do a particular basic physical examination is when he feels inadequate doing it anymore because he has not been doing it for a long time. Or, when he feels it will be done by a physician well versed in doing it.  
Note: Breast physical examination is expertly done by general surgeon who are breast specialists.  Gynecologists, by virtue of their training (particularly in the Philippines), are not breast specialists.  The general surgeons do not question gynecologists doing breast physical examination on all their female patients as this is considered a basic physical examination procedure.
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