Informed consents, documentation of encounters, and Larry Nasser

I hate to perseverate about this particular scandal, but the more I think about this situation, the stranger it appears. Dr. Nassar is a doctor and by any standard, his interactions with the gymnasts represent patient encounters. Furthermore, many of these patient encounters were with under aged minors.

I see patients in this age group as well. My encounters happen almost invariably in the presence of some adult guardian. If I do anything to these patients, it is done after informed consent is done. Not always written consent but with explicit permission granted after explaining what I am planning to do and what specifically I hope to accomplish. This is followed by a note in the medical record which documents the events that transpired.

There is a large void in the news reports when it comes down to descriptions of of specific contexts of the assaults perpetrated by Dr. Nassar. The implication is that he touched young girls inappropriately under the guise of treatment.  I don;t work in the sport medicine field and I don't know what their standard workflows and processes are. Do practitioners routinely ask for consent prior to doing manipulations? How do they handle this for minors, especially when the interventions may happen repeatedly and during times when parents are not around? What sort of documentation do they do? Does the documentation acknowledge consent was granted and for what?

I don't know for certain but I suspect that Dr. Nassar and much of the sports medicine world operates in a way which is very different from from the rest of medicine. The rest of medicine is adherent to protocols put in place to protect both practitioners and patients, which also allows for what otherwise represents violation of personal spaces. Are these protocols applied in the realm of sports medicine? It does not appear to be the case. Are there notes written by Dr. Nassar describing each therapeutic intervention, the justification for the intervention, the outcome desired, and subsequent measurement of whether the specific outcome was attained? I do not think so.

Is there evidence that either the gymnast or an adult guardian was fully informed regarding the specifics of the intervention proposed (I am going to do this manipulation requiring me to touch this part of your body), the purpose of the intervention, and the outcome desired. I do not think so.

In my opinion, there are minimum standards which should be required for all doctor (or non-MD clinician) - patient relationships and interventions. These include explicit recognition of patient autonomy, informed consent (not all of which is written informed consent), rigorous protocols for dealing with vulnerable populations (including minor children), and at least a minimum of documentation of intervention deployed which captures the above elements. Furthermore, patients and their adult guardian should have access to all of the medical documentation.  If Dr. Nassar had been required to adhere to these minimum standards, I doubt the events would have transpired.