Expat Expectations in Patient Care As a professional expat with two passports and permanent European Residence working in South Holland, it never ever occurred to me that I had to be extra vigilant when entering into a patient doctor relationship, especially when discussing the possibility of surgery. But here I am in The Netherlands and as good as the health care system is there are differences in the approach to how medicine is practiced. Recently, I was preparing for an OBGYN related surgery in Germany. My Female Dr asked me to take into consideration what my needs would be if there were an emergency and because I have Dutch Health Insurance, it would financially in my best interest to have the surgery performed in The Netherlands. My German Dr runs an all-female clinic so the possibility of having a male Dr, residence or medical student is simply not an option. I was asked if I had any objection to being treated by a male Dr, for instance, or a residence or medical student. During this discussion I also became aware of the possibility of non-consensual pelvic exams that are very often performed on female patients while anesthetized at teaching hospitals in The Netherlands. My Dr’s position on the aforementioned was to write a patient care plan outlining what I am willing to consent to or not. The concept a non-consensual pelvic exam being performed by medical students and residences for training purposes was upsetting. It was unclear to me why this could not be discussed during the patient intake. Concerned, I made two international calls, one to New Zealand and the other to my former OBGYN in New York for some clarification on the matter. I was told non-consensual pelvic exams are an outdated practice and no longer legal in both New Zealand and the United States of America. Consent for all examinations must be given by the patient. I then asked my Dutch husband, also a Doctor and specialist (non-obgyn) to ask colleagues at several Dutch teaching hospitals about this practice and if they had ever participated in performing a non-consensual exam on a female during her surgery. The answer was yes. Non-consensual pelvic exams on anesthetized women are a standard medical teaching procedure. My husband, equally surprised because he had also never ever heard of this, supported me in better understanding the principals behind the teaching procedure. A review of the fine print on the admissions documentation illuminated that under an umbrella clause it was noted that ‘medical students and residences will be involved in patient care and during surgery, might examine the patient’. So what is an Umbrella Clause – An umbrella clause is a general statement that applies vague language using words like; sometimes, usually, inevitably, implicitly or generally, that may imply or include concept versus definitive ideas. Example: The hospital is an academic institution and medical students may sometimes/usually/inevitably/generally participate in surgeries and patient examinations, while specifically not mentioning facts for example; medical students will be preforming invasive non-consensual pelvic exams while the patient is unconscious. The umbrella clause serves several functions. Primarily it is simply not practical for the hospital to outline every single detail and such scrupulous documentation takes time, whichhospitals already don’t have enough of. Second, it would appear that there is a pervasive sense of entitlement within the teaching hospitals and based on this sense of entitlement it is not in the hospitals interest to duly inform patients of their rights. Sadly, captured within this belief is the notion that if patients were to understand the full extent of what would happen to them, they would refuse treatment. Lastly, there is underlying interpretation that patients implicitly understand that they are at a teaching hospital and it is inevitable that medical students and residences will be given the opportunity to practice on patients regardless of whether or not the patient has or has not given direct consent. As a direct result of our findings, I wrote up a Patient Care Plan. Within this document I captured all my principal non-consent statements and outlined what I would think is appropriate for a non-emergency surgery. Further to this I rang my huisarts (GP) and requested that my care plan be officially filed. This request was honoured and a very concerned and supportive huisarts recommended that I always have a copy of my care plan available when visiting any doctor and that it is important to be clear and concise when expressing ones values and needs. The Patient Care Plan and Patient Safety: So in closing this is what we have learned. Emotion will almost always override logic and when confronted with such potentially overwhelming information, try to make the issue smaller instead of allowing it to emotionally get the better of you and become unnecessarily bigger. Prevention, prevention, prevention is the best action. Writing a Care Plan outlines your wishes so the treating medical team, should it involve several people who are often interchangeable, will do all the explaining when you feel overwhelmed and vulnerable. To Talk, talk, talk is the optimal solution, and continue to talk until you feel completely clear in what and how your procedure will be, and please, please understand that you are entitled to be treated fairly, with dignity and it is the Doctor who is partnering with you, your body, your feelings, your opinion, and you have the final say in how you wish to be treated.