Pelvic exams by students, residents are growing risk

The public is becoming aware of a practice that makes even some experienced medical professionals uncomfortable, greatly increasing the chances that an irate patient will sue for malpractice or even file charges of assault. Though it has been common practice in many health care institutions for decades, the practice is increasingly coming under fire from critics who say it just isn’t right.

The practice: medical students and residents performing pelvic exams on women who have been anesthetized for surgery, without any medical need, and usually without consent. Several hospitals report they have recently revised policies to prohibit the practice.

Concerned medical professionals are speaking out and sparking a barrage of criticism from both the health care community and the public. While this educational practice poses no physical harm to the patient, most people are shocked to hear that such an invasive exam is performed without the patient’s knowledge, says Peter Ubel, MD, director of the University of Michigan (U-M) Medical School’s Program for Improving Health Care Decisions, and associate professor of internal medicine, in Ann Arbor. Research shows that most women are willing to allow medical students to perform the examinations, but with the proviso that permission is asked for and granted, he says.

Nevertheless, many OB/GYN departments do not regularly inform women when they will be undergoing pelvic examinations by medical students while under anesthesia. In addition to the possible malfeasance against the patient, he says such policies may encourage a more callous or lackadaisical attitude about informed consent among young physicians. Pelvic exams aren’t the only activity that should cause concern, but Ubel says they are the most likely to produce outrage from patients.

"Pelvic exams carry a special concern in terms of privacy," he says. "This is a very emotional issue. People use terms like rape, which it clearly is not, but it makes people think of that. People say they would feel violated. They wouldn’t feel the same if a student came in and palpated the abdomen to feel a mass or stuck their fingers in the mouth to feel an oral mass."

A growing risk

Ubel suggests that risk managers should see this issue as a growing risk because patients are becoming more aware of it, leading to the possibility of lawsuits or even charges of assault. While he knows of no such legal action so far, Ubel points out that most patients who were examined are left with no clue that the violation took place. He also suggests that the blanket informed consent used by some teaching hospitals might not fend off a lawsuit if the patient feels her privacy was violated.

"Many times people will come into a teaching hospital and will see somewhere in the mass of paperwork a couple of lines indicating that they will be interacting with medical students," Ubel says. "But that doesn’t mean that students and trainees can be involved in every aspect of care without further permission. Those lines don’t mean that the patient has signed on for whatever else the teaching hospital decides to do. I think a patient can very easily say they didn’t see those lines in the consent form or didn’t realize it would involve this kind of exam."

Ubel says he and his fellow researchers wondered whether completion of an OB/GYN clerkship was associated with a decline in the perceived importance of securing permission from patients before conducting pelvic examinations under anesthesia. Their research suggests the answer is yes, he says.

"We found that medical students who have not yet done their OB/GYN clerkship place more value on securing consent than do medical students who have completed the OB/GYN clerkship," Ubel says. "The OB/GYN clerkship seems to be the defining event in this erosion, as opposed to gradual erosion throughout students’ many clerkships or rotations."

A question of consent

In a recent study, Ubel and his colleagues looked at questionnaires that were distributed in 1995 to all 4,511 medical students at five Philadelphia-area medical schools (Am J Obstet Gynecol 2003; 188:575-579). Students were asked how important it would be for a patient to be told that a medical student is going to perform a pelvic examination under anesthesia. Researchers tested for associations between completion of an OB/GYN clerkship and attitudes toward pelvic examinations using linear regression to adjust for gender and total amount of clerkship experience.

"Something clearly happens during OB/GYN clerkships that is associated with students placing less importance on consent for pelvic examinations under anesthesia," says Ubel, who was on the faculty at the University of Pennsylvania’s Center for Bioethics at the time the study was conducted.

The experiences of two of the authors as medical students suggest that consent is either not routinely obtained for educational pelvic examinations performed by medical students in the operating room or, at best, somewhat murky.

"In our medical student experiences, we were unclear whether the patients we were asked to examine had given explicit consent to be examined. The study suggests that similar experiences are associated with a decline in the importance students place on seeking permission for such examinations," Ubel says. One of the authors refused to conduct such exams when he was a medical student, he says.

The norm

At the U-M Health System, however, policy and practice are in unison, and patient consent is the norm, says Maya Hammoud, MD, clerkship director at U-M’s department of obstetrics and gynecology.

"It is the nature of education that students learn both by observation and by doing. We place a great value on developing a sense of professionalism in our medical students, and we expect faculty to follow policies about informed consent so medical students can emulate what they see in a positive way," she says. "In addition, here at UMHS, patients are informed that pelvic examination under anesthesia are conducted when necessary to assure safer performance of the operation, and that medical students may participate in these examinations."

Ubel says he and his colleagues believe the data may reflect students’ strategies for coping with the knowledge that they participated in an activity that, if discovered, could cause patients to feel violated. As a result, some students may simply deny the importance of obtaining consent in the first place.

"Medical educators can remedy this decline in students’ attitudes toward pelvic examinations under anesthesia by making sure that students perform such examinations only on patients who have explicitly given their consent," he says. "Students will still have a good learning experience, and they’ll also learn important lessons about medical professionalism and ethics."

Altered policies

Several health care providers have announced recently that they have altered their policies to prohibit pelvic exams on unconscious patients if they have not given prior consent. Harvard Medical School adopted such a policy in the mid-1990s, and in addition, required that the student be a part of the medical team treating the patient. The University of California — San Francisco School of Medicine responded to complaints in the 1990s by adding a line to its consent form indicating that women undergoing gynecological surgery may be given a pelvic exam by medical students while they are anesthetized.

Policies vs. behavior

While not criticizing those particular institutions, Ubel says such policies may not be enough.

"Lot of places came out and said we have policies about this, but written policies don’t do any good if people don’t modify their behavior," he says. "Word needs to come down from the chair of OB/GYN. Maybe risk managers can whisper in their ears and say, Tell all your faculty. No student exams in the operating room without permission. Period.’"

Ubel notes that the pelvic exam comes under particular scrutiny because many patients would see it as an invasion of privacy, but it is not the only procedure worth considering. A rectal exam might pose the same sort of problem, he says.

"But taking blood pressure or listening to someone’s heart? Probably not a problem," he says. "If someone is asleep in the operating room and the doctor calls the student over to listen to a heart murmur, I have a hard time getting excited about that."