Each recommendation issued by the National Human Rights Commission (CNDH) is a disastrous case. In 2021, 74 recommendations related to health issues were issued; it is a high number and some people might say that doctors are being persecuted. From my point of view, after reading the 74 recommendations, I can say that in the vast majority of cases there is responsibility of the health institutions and the workers. Let’s read the recommendations to know what to modify and prevent the same problems from occurring again.
In relation to recommendation 128/2021, the facts are as follows:
A woman who is 10 weeks pregnant comes to your Family Medicine Unit for her first prenatal care consultation. In said consultation, she was seen by a medical intern of social service without any resident doctor, assigned or nursing staff being present at that time. During the consultation, the intern doctor decides to perform a vaginal touch supposedly to check that there was no discharge, since the patient had previously presented vaginal discharge; which, at the time, had been evaluated by a private doctor. The patient narrates that the touch was repeated, in various ways, and that, in addition, there was touching of her breasts by the intern doctor.
The experts who heard the case confirmed that there were recent traumatic injuries, in addition to psychological alterations derived from said event.
In this case, the CNDH determined that the medical intern, the assigned doctors who did not supervise the medical intern, the authorities of the Medical Unit for not providing accompaniment to the victim despite being aware of the facts and the Health Institution since they are obliged to promote, respect, protect and guarantee human rights.
In this case, many things happened that, unfortunately, are common in our health system and are poorly done. The first of these is called social service, an institution that was created 80 years ago and every day makes it clear to us that it is contrary to the legal and ethical standards of current medical practice. No one is interested in creating clear legislation for social service because it is clear to everyone that it is an anachronistic solution to the lack of medical care in the country.
An important problem is that few people know what the legal status of medical interns is, and hence problems arise as to what they can and cannot do. In a previous column titled What are social service medical interns? I described the legal status of these students; their status is that of students with temporary authorization to practice the profession. They are not workers, but they are not students like the interns either, since they have an authorization to practice the profession.
Can social service interns perform vaginal exams? My opinion is that according to the current legal framework, they can. According to NOM-009-SSA3-2013 (number 8.1.), interns must provide medical attention. At no time is it mentioned that it must be under surveillance or supervision. There is no law or regulation that expressly prohibits performing vaginal examinations by social service interns. From my perspective, interns can perform complete physical examinations, including vaginal examination, when these are indicated and in the presence of medical or nursing personnel. In its recommendation, the CNDH mentions that social service interns must be supervised at all times. Although I agree that interns are supervised, this is not established in any regulation or law. The ideal is that the interns are supervised, but the law is not clear and the reality is contrary to this practice; interns in many cases are alone. If the criterion were adopted that they can only perform tests if they are supervised, a large proportion of our medical interns would find themselves breaking the law every day, because many interns are alone in their health centers and clinics without supervision and surveillance.
It seems to me that we are faced with a criterion that puts the intern between a rock and a hard place. On the one hand, the health institution leaves him alone and, on the other hand, the CNDH forces him to be supervised.
In this case, the medical intern performed the examination without supervision and there was no clear indication to perform vaginal examination. We must remember that a vaginal examination should always be done in the presence of another person who is a health worker, whether a doctor or nurse, and only when there is a medical indication and the procedure has been explained to the patient.
Are the attached doctors really responsible for not supervising the intern? In other countries, when the actions of doctors in training are analyzed, responsibility is divided into two: when they act under the orders of their superior and when they act autonomously without consulting. In this case, it seems to me that the intern doctor acted without consulting one of his superiors and did not tell anyone that he was going to perform a vaginal examination, for which he would be solely responsible. On the other hand, if the office was assigned to an assigned doctor and this left only the intern, in this case if the assigned is responsible. I only know of the case because of the public version of the recommendation, but it would be interesting to ask where the adherents were. Who was in charge of that office?
The performance of social service interns is always a cause for concern. From my point of view, social service should be reformed or disappear. These practices must not continue. Social service has been in existence for more than 80 years and it is clear that its structure is no longer compatible with the ethical and legal standards of current medical practice. The only way to prevent these cases from occurring in the future is by profoundly transforming the nature of social service and preventing medical interns from providing medical care without supervision.
If you were interested in my column, I invite you to read my books: In the medical residence and From victim to tyrant: R2 chronicle, published on Amazon.mx in physical and digital format or follow me on my twitter account: @Sarmientomau.