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Pelvic exams while under anesthesia sparks debate
October 7, 2012 at 7:19 AM
Pelvic exams while under anesthesia sparks debate
By Karen Rowan
Published October 05, 2012

As a medical student, Dr. Shawn Barnes had an experience that he says left him feeling ashamed and conflicted. During his rotation through the obstetrics and gynecology ward of a teaching hospital in Hawaii, Barnes performed pelvic exams on women under anesthesia without the women's explicit consent to the procedure. The women were all having gynecological surgery, and had signed a long form indicating they agreed to allow medical students to be involved in their care.

However, to Barnes, the "implicit consent" patients gave when signing the forms didn't ensure they understood exactly what happened while they were unconscious — a relatively inexperienced medical student palpated their ovaries and uteruses to check for, and better understand, potential abnormalities in these organs.

"For three weeks, four to five times a day, I was asked to, and did, perform pelvic examinations on anesthetized women," Barnes wrote in an editorial published in the October issue of the journal Obstetrics and Gynecology. Teaching hospitals should stop this practice, Barnes told MyHealthNewsDaily. Instead, patients should be asked to "explicitly consent" to the procedure, meaning they specifically say they will allow a medical student to conduct a pelvic exam.

Two doctors at a Boston hospital, writing in a counterpoint to Barnes' editorial, say they agree that obtaining only implicit consent is "morally unsound," but also say that this practice has largely faded away. Guidelines from doctors' groups say that women should be fully informed about the procedure, they noted.

"We have many providers who trained in other institutions, and in conversation with them," it's clear that women are usually asked specifically for their consent to a student-performed exam, said Dr. Carey York-Best, an obstetrician and gynecologist at Massachusetts General Hospital and one of the doctors who wrote the counterpoint to Barnes' editorial.

But Barnes says the exams are done without explicit consent more often than these doctors indicate. A 2003 survey of Philadelphia medical students found that 90 percent reported being asked to perform pelvic exams on women who had not explicitly consented to the procedure.

Both Barnes and York-Best said there are no recent data available on exactly how many hospitals nationwide are not abiding by the guidelines recommending that explicit consent be obtained.
In any case, Barnes said that guidelines do not govern real-world practice — for this, laws are needed. During his residency, Barnes said he raised his concerns regarding pelvic exams with his superiors, but was told these exams were a long-standing, standard practice. "In fact, I was told I was the first medical student or resident in institutional memory to express concern over the practice," he wrote in his editorial. York-Best said such laws would potentially overregulate doctors' activities, and that the field is already far more regulated than many others.

Why not just ask for permission?

Performing pelvic exams on anesthetized women just prior to surgery provides medical students with a unique and valuable learning experience, Barnes and York-Best both said. For one, muscles relax under anesthesia, allowing the exam to proceed more easily and giving the surgeon and medical student a clearer picture from which to plan the details of the surgery.

Additionally, women undergoing surgery have conditions that make their anatomy abnormal. Most patients who come in for routine exams performed by medical students don't have gynecological diseases, but medical students need to be able to recognize and diagnose abnormalities.

In his editorial, Barnes presented the arguments he heard — from attending physicians, residents, and other medical students, along with published medical literature — that a woman's signature on a long form was sufficient proof of her consent.

One argument is that such consent forms are simply the standard practice, so the exams are not an issue. But the fact that professional guidelines — from groups such as the American College of Obstetricians and Gynecologists and the American Medical Association — say that explicit consent is needed shows that this should not be the standard practice, Barnes said.

Another argument he heard is that medical students don't ask for specific permission to retract tissue or cut sutures during surgery, and that the pelvic exam portion of the procedure is no different.
But Barnes argues that it is different. In fact, male medical students must be chaperoned when performing pelvic exams on conscious patients, but not when they remove surgical staples — this requirement reflects an understanding on the part of medical practitioners a pelvic exam is a more personal practice.

Do guidelines do enough, or are laws needed?

York-Best and her co-author, Dr. Jeffrey Ecker, suggest that the physician responsible for the patient's care should ask the patient for permission to allow a student to perform the exam, ideally well before the surgery. Patients should also be given the opportunity to meet the medical student prior to the surgery, they write.

Most patients are willing to let the student do an examination when asked by their own physicians, York-Best said, pointing to a 2009 study in which 74 percent of patients consented to a student performing a pelvic exam when they were asked by their doctor. In contrast, another study found that 53 percent consented when they were asked by students. "When it is a stranger, especially a nervous or awkward student, who asks, they do not yet know if they can trust that person, and are likely to err on the side of saying no," York-Best said.

It's important for doctors at teaching hospitals to advocate for the teaching process in order to ensure that their students receive adequate training, she said. Barnes called this "a good idea," but maintained that laws are needed to make sure that women understand what they are consenting to.

Hawaii is now one of four states (California, Illinois and Virginia are the others) where doctors are legally required to obtain specific consent for pelvic exams under anesthesia. The Hawaii law grew out of Barnes' outreach to lawyers about the issue, and he testified before the state legislature regarding the practice while the bill was under consideration.

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  • JoshRachelsMAMA
    October 7, 2012 at 8:22 AM
  • TCgirlatheart
    October 7, 2012 at 8:25 AM

     And some wonder why people don't trust Dr.'s in general...

    Although, not having to actually feel my pelvic exam is tempting.  ;)

  • cjsbmom
    by cjsbmom
    October 7, 2012 at 8:32 AM

    While teaching hospitals have their merits, stuff like this makes me really angry. It's degrading, and I doubt most of these women would have consented to it had they known exactly what they were consenting to.

    When I had my son, I found myself becoming increasingly annoyed by the number of "students" who were in and out of my room, including during delivery. I had specifically asked that they *not* be allowed to be a part of my delivery or recovery, and my wishes were ignored. So I have a hard time trusting any hospital that would do something like this while a woman is unconscious. Any time sexual/reproductive organs are involved, this shouldn't even be an option, IMO. There's too much room for abuse to occur, and how would anyone know?

  • UpSheRises
    October 7, 2012 at 8:35 AM

    I think they should have to obtain explicit consent.

  • Euphoric
    October 7, 2012 at 10:08 AM


  • JoshRachelsMAMA
    October 7, 2012 at 10:54 AM
    I'm writing this into my birth plan. It's offensive.
  • Woodbabe
    October 7, 2012 at 10:54 AM

    I'm knocked out, I'm there for gyno surgery...the doctor HAS to learn one way or another. Here's the big the Attending Doctor also doing a final check of the girly parts to confirm diagnosis before slicing and dicing? If so, is an explicit consent required or is it considered simply a part of the medical treatment?

  • AdrianneHill
    October 7, 2012 at 10:56 AM
    Icky again.
  • JoshRachelsMAMA
    October 7, 2012 at 10:59 AM
    That's a good question. Perhaps if you're not alone (your partner is waiting for you), they'd have to obtain consent from him? Or inform you before you go under that its a possibility.

    Quoting Woodbabe:

    I'm knocked out, I'm there for gyno surgery...the doctor HAS to learn one way or another. Here's the big the Attending Doctor also doing a final check of the girly parts to confirm diagnosis before slicing and dicing? If so, is an explicit consent required or is it considered simply a part of the medical treatment?

  • Ziva65
    by Ziva65
    October 7, 2012 at 11:14 AM

    I do think it should be more explicitly outlined and explained to the women in advance, as part of the consent. However,

    It appeared as if they were directly with the surgeon just prior to the procedure, in which case, it's easily understood, it is a teaching hospital after all.  It doesn't sound like there are multiple students doing this on the same patient time after time (which the title sort of implied), it is directly associated with the procedure for which they are there. Really not any different than if the person were awake in the exam office with a student there.

    That is what you get at a teaching hospital anyway. In my nursing rotations in ICU guess where the arterial blood gases got done by students, in the ICU.

    I 1) never go to a teaching hospital and 2) when I have been somewhere where there are medical or nursing students, I let them watch but will not be practiced on :) I know it's important, and I did it too (as an FNP), but I have always obtained a clear consent when I was a student. And, not at all offended when they said no, as I too say no :)

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