Conversations We Shouldn't Still Be Having: Pelvic Exams Under Anesthesia

September 26, 2012

In the October issue of the journal Obstetrics and Gynecology, a medical student writes of his discomfort with a practice many people may be surprised to learn still occurs — medical students practicing pelvic exams, without explicit consent, on women who are under anesthesia for surgery.

The student, Shawn Barnes, writes that the practice left him “ashamed.”

“For 3 weeks, four to five times a day, I was asked to, and did, perform pelvic examinations on anesthetized women, without specific consent, solely for the purpose of my education,” writes Barnes. “To my shame, I obeyed.”

He continues:

As a medical student, I am all too aware of the hierarchy that exists during training. My medical education experience has reinforced the notion that the medical student should not question the practices of those above him or her. I was very conflicted about performing an act that I felt was unethical, but owing to both the culture of medicine and my own lack of courage, I did not immediately speak out against what I was asked to do by residents and attendings.

His commentary, titled “Practicing Pelvic Examinations by Medical Students on Women Under Anesthesia: Why Not Ask First?,” is available only by subscription/purchase, or through a library, as is a related editorial in the same issue, “Pelvic Examinations Under Anesthesia: A Teachable Moment.”

Carey M.York-Best and Jeffrey L. Ecker, authors of the editorial, remark that no one knows how often these exams occur, and they point out that teaching hospitals, which are expected to train students, do ask patients for general consent for students to be involved in their care. However, they rightly note that blanket consent is inadequate when it comes to pelvic exams:

After all, consent forms at many teaching hospitals include a statement outlining the involvement of students in patient care. Yet we believe that, even if such phrases may meet the letter of recommended conduct, they often are overlooked and a few words on an already too-long form do not represent true informed consent.

Barnes also calls these forms inadequate, and he also doesn’t buy the argument that women should expect such things when they go to a teaching hospital:

We first must remember that patients tend to seek care at facilities that are geographically nearby, where their regular physician has privileges, or where their insurance is accepted. Consent forms at teaching hospitals tend to use language stating that medical students and residents may be involved in that case. That involvement is not specified.

Practicing pelvic exams on women under anesthesia purely for teaching purposes — not for the women’s medical benefit — is not a new practice. However, many may have assumed it had largely stopped, particularly after a 2003 study (which I discussed several years ago) drew a lot of attention to the issue, causing many medical schools to clarify their policies and/or seek women’s explicit consent. Several professional medical organizations have also denounced the practice.

The study was based on a 1995 survey of students at five U.S. medical schools. The researchers found that only about a third of the students thought it was “very important” to get consent prior to doing a pelvic exam. Students who had actually done an ob/gyn clerkship were even less likely to think consent was important. Almost 10 percent of those students actually responded that explicit consent was “very unimportant.” The overwhelming majority (90 percent) of the ob/gyn clerkship students had performed pelvic exams on women under anesthesia.

Back to 2012 — Barnes informs readers that as a result of a bill signed into law this past June, Hawaii (where he studies) will join California, Illinois, and Virginia in making “unconsented” pelvic examinations against the law. For those interested in learning more, his testimony is included among these documents supporting the Hawaii bill.

This may be an opportunity for advocacy in other states, where it may be possible to get similar laws passed.

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