Saturday, March 03, 2007

What's Missing From Model Pelvic Exams

As mentioned in a previous post, some medical teaching institutions have switched from having medical students perform pelvic exams on (often unaware, non-consenting) live women with technological devices, such as this pelvic ExamSIM from Medical Education Technologies, Inc. An author comment (1) following the article reporting disturbing attitudes toward consent (2) rightly points out that these models omit important information about performing pelvic exams, namely the patient's experience of pain or discomfort, and the interaction with the patient as a whole. It takes but a glance at the image to the left to realize that existing models are disembodied and standardized. How many of you would look at your own genital region and think that it is similar to the model shown? What can a medical student learn about pain and natural variations in human anatomy from a model so removed from real women's anatomy and experiences? While anatomical models may be a better option than assaulting unconscious women, I've yet to see a woman's body that looked anything like the image shown.

The authors state, "Students are not learning how to palpate for pain—an extremely important indicator of pathology—and the surgical focus on anatomy does not emphasize the importance of examining each woman with gentleness, with sensitivity to her psychologic state, and with respect for her intellectual presence. When these repeated preoperative educational examinations are performed without the patient's informed consent, the cost to both patient and student is even greater. A tremendous number of women describe these examinations as a form of violation; that fact alone should warrant change. Additionally, our survey research has shown that medical students place less value on the importance of informed consent after participating in the third-year obstetrics-gynecology clerkship than they placed on it before the clerkship. The bottom line is this: teaching institutions should make sure that students do not examine patients, whether alert or anesthetized, until someone first receives the patient's informed permission."

Another published comment (3) in response to the article more pointedly states, "hospital administrators who allow medical students in their facilities to perform pelvic examinations on unconsenting anesthetized women ought to consult with their legal counsel concerning the definition of rape in their jurisdiction."

1) Ubel PA, Silver-Isenstadt A. Author reply. Am J Obstet Gynecol. 2003 Dec; 189(6):1808-1809. [Full-text]
(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) Coxe MF. A change in medical student attitudes of obstetrics-gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient. Am J Obstet Gynecol. 2003 Dec;189(6):1808 [Full-text PDF]


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