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]