Saturday, March 03, 2007

Pelvic Exams and Informed Consent

The New England Journal of Medicine has a perspective piece by Adam Wolfberg in the current issue (1), "The Patient as Ally — Learning the Pelvic Examination," which addresses the issue of teaching pelvic examinations to medical students. It provides some telling information about the history of how this exam was taught, stating, "in contrast to ambulatory care, the gynecologic operating room has historically provided medical students with an opportunity to learn this exam: they could perform it in anesthetized patients immediately before surgery." This practice became extraordinarily controversial when it became more widely known that pelvic exams were often performed on anesthesized surgical patients without their knowledge or consent, as a teaching tool rather than for medical care. According to the piece, "Academic gynecologists were accused of using patients as unwitting "training dummies" — a reaction exacerbated by the report's revelation that students who had completed an Ob/Gyn clerkship were less likely than other students to believe it is important to obtain the patient's consent for such an exam."

The study cited (2) found that only 51% of those who had completed an OB/GYN clerkship thought consent prior to pelvic exam was "very" or "somewhat" important - 24% were "neutral," 15% found consent to be "somewhat unimportant," and 9% thought consent was "very unimportant." Those who had not done an OB/GYN clerkship were only somewhat better on the issue of consent, with just 70% stating it was "very" or "somewhat" important - still far short of the 100% consent women might reasonably expect. Interestingly, the survey was conducted in 1995, but this paper reporting the results wasn't submitted until 2002 or published until 2003. Women familiar with the practice of performing pelvic exams without consent may assume it happened "a long time ago," but these findings suggest otherwise.

Wolfberg provides disturbing insight into how complaints about this practice are perceived by physicians. Regarding the distinction made by those opposed to the practice who insist that the patient's consent is absolutely necessary for procedures done solely as a teaching tool, the author states, "This stance rankles physicians who downplay this distinction — particularly those who are uncomfortable asking their patients to give written permission for a medical student to perform an operating-room examination. Patients, they argue, are already nervous about surgery, especially when they must sign the surgical consent form describing everything that can go wrong; the last thing they want at that point is to be asked to allow a medical student to examine them." This paternalistic attitude is extremely troubling, a sign that some physicians think women shouldn't have to worry their pretty little heads about what might be done to them without their knowledge while they're knocked out in a hospital. Rather than coming to the conclusion that the exam should then not be performed without explicit consent from women, individuals and institutions have in the past jumped to the conclusion that they simply shouldn't ask or tell when violating women's vaginas.

In response to the controversy, Wolfberg explains, many medical schools have clarified their policies, banned this activity, and switched to teaching the exam with a paid live volunteer or with technological device (such as the Pelvic ExamSIM, a ~$19,000 device), which may not reflect the full range of women's anatomy and experience of the pelvic exam. Others have decided that a fully informed consent approach might actually work - contrary to physicians' fears that women would refuse to be examined for teaching purposes, one OB/GYN residency director found (3) that "more than 80% of patients agreed to let a student examine them in the office if they were asked in advance and didn't feel that they were being pressured."

1) Wolfberg AJ. The patient as ally--learning the pelvic examination. N Engl J Med. 2007 Mar 1;356(9):889-90. [Extract - 1st 100 words]
2) Ubel PA, Jepson C, Silver-Isenstadt A. Don't ask, don't tell: a change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient. Am J Obstet Gynecol. 2003 Feb;188(2):575-9. [Full-text]
3) Berry RE Jr, O'dell K, Meyer BA, Purwono U. Obtaining patient permission for student participation in obstetric-gynecologic outpatient visits: a randomized controlled trial. Am J Obstet Gynecol. 2003 Sep;189(3):634-8. [Full-text]


Blogger Unknown said...

This performing pelvic exams on female patients without their consent or knowledge is appalling!
In addition, what benefit is their to a medical student learning on someone who is completely relaxed and unaware? Better to learn on patients who are awake and nervous as those are the ones they will have to perform most pelvic exams on anyway.
Also, it is time that phyysicians learned how to perform a SENSTIVE PELVIC EXAM ON ALL WOMEN. Pelvic exams can be traumatic for women with a history of abuse. Do med students learn how to perform sensitive exams on this large segment of the population? Probably not.
If they want to learn more on this issue, they should check out one web site researched and put together by health care providers that addresses this issue:

3:09 PM  
Anonymous Anonymous said...

This seems so strange to me, actually. I've heard about this practice being used in medical schools, but I thought it had been outlawed ages ago. I'm a student and I do pelvic exams on *conscious* women *with* their consent all the time. All you have to do is introduce yourself as a student, ask her if it's okay if you do an exam after your preceptor has checked her, and most women are very willing to allow it, even during labor...even when they're in a lot of pain. There has only been one or two times in my entire career so far where a patient has requested that I NOT do an exam on her, and we complied. It's really that easy.

The above points about learning how to do a sensitive pelvic exam are also very valid. Pelvic exams during labor hurt! How is a student supposed to learn how to be gentle if he/she is always practicing on unconscious women? Sheesh.

5:58 PM  
Anonymous Anonymous said...

I'm not sure I really understand getting all het up over pelvics while not caring in the slightest about breasts or any of the other stuff medical students are told to examine for pathology whenever the patient has something relevant. And of course there is always the surefire way to avoid the situation entirely: go to a private practice doctor.

The "approval numbers" for students when patients are asked are quite misleading. It's more like 100% for women and 25% for men, if that (and I've seen this quite a bit). Now personally I couldn't care less because doing pelvics sucks, but you're getting a generation of ER docs and others who can't detect OB/GYN pathology properly. Ah well, price of progress I suppose.

10:51 PM  
Anonymous Anonymous said...

In theory this no longer happens in the UK as it was meant to have been mad a requirment years ago that consent is obtained before any intimate examinations by trainees.

In 2003, the BBC reported that this policy was not being followed, so I'm not assuming they are following it now.
The reason this stopped was they got caught. There was no investigation to find out how far spread this abuse was (I cant call it anything else) and it would seem patients were not told. This means if you went through Bristol and other teaching hospitals, you may have been sexually assaulted or may not have.

4:25 AM  
Blogger Rachel said...

It's an issue of informed consent and violation of women's rights and bodies. I don't think it's appropriate to handle the situation by simply telling women to try other (private practice) doctors in hopes that this sort of thing won't happen. Many women in the U.S. live in areas where there is a limited choice of providers - the only hospital that does their surgery may be a teaching hospital. Legally and ethically, the burden is on the physicians to obtain consent for what they do, not the patient.

8:06 AM  
Anonymous Anonymous said...

So, does the medical profession perform prostate exams on unconcious men? I think the answer would be no (although I'd love someone to prove me wrong) - but its ok to violate a womans bodily autonomy. Shame.

4:07 PM  
Blogger Unknown said...

this is rape, pure and simple. being unconscious, having not given permission and not being told about it, it is a violation of one's body to have someone else's penis, or someone else's medical instrumentation, inserted into one. there is no other word for putting things into unconscious women's vaginas without knowledge or permission than rape. that it is training for medical students does not change the fact that it is rape.

8:11 PM  
Blogger MomTFH said...

I started writing this when this post was first published, but I wanted to develop it more, possibly into a post on my own blog. Thank you Feministing for reminding me about this, and here it is:

I trained as a midwife for two years, and am now a medical school applicant planning on doing family practice with obstetrics.

The ethics (or, should I say, complete lack of ethics) underlying doing a pelvic exam on an anesthetized patient without any clinical relevance to their case for instruction purposes, to me, is a clear issue. Informed consent, always. In fact, some online discussions of this have correctly pointed out that a pelvic exam without consent violates many rape statues.

However, I primarily want to discuss the educational experience.

I think doing a vaginal exam on a dummy like those is almost as useless as doing one on an anesthetized patient. I have seen and used a similar product in classes, and it is nothing like the real thing.

First of all, it is overwhelming for most new students to overcome the newness and all the associated baggage (of the student AND the patient) of asking a patient to disrobe, seeing a vagina (and they really really do vary in shapes and sizes and decoration) and then inserting their fingers into the vagina.

Do they ask permission? Do they put the patient at ease? What terms do they use for the vagina? Do they touch the patient on another part of their body first, like an arm or shoulder, before putting on the gloves?

Have they checked the chart to see if this patient has disclosed a past of sexual abuse? How about infectious disease?

Do they know to warm the speculum in their gloved hand first while explaining what the procedure will entail and why they are doing it? Do they remember to use lubricant? To turn the speculum to one side as it inserts, but to watch the thighs? To not press on a woman's clitoris or rectum with the speculum or the knuckles?

Are they looking for scars, bruises, infections, smells, veins, or any other clues?

If a woman is not awake, she will not tense up as many do. If she doesn't have a gynecological issue to which a pelvic exam would be relevant as a diagnostic tool, which they most likely DON”T because they are there for unrelated surgeries, this is not going to train these doctors-to-be to diagnose pathologies. What would train them would be to do an appropriate Ob/Gyn rotation in which they saw live patients and observed and participated in true medical education.

5:52 AM  
Blogger Rachel said...

Thank you for your comment - I think you raise a very important point about making sure the educational experience is valid, and some reasons why a simple technological model isn't a good solution, either.

7:59 AM  

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