Some patients undergo surgery and wake up to find multiple students practiced pelvic exams on them without their consent.1 “These situations are certainly the exception and not the rule. But they highlight an area of medicine where we can improve practices around informed consent,” says Karampreet Kaur, MD, a resident in the department of obstetrics and gynecology at Hospital of the University of Pennsylvania.
Kaur and colleagues wanted to learn more about students’ opinions of informed consent processes used for these exams. “We wanted to guide improvements in informed consent practices that prioritize the safety of the patient and the learner,” Kaur says.
They surveyed 305 medical students who completed an obstetrics and gynecology clerkship in 2019 or 2020.2 Eighty-four percent of students had performed at least one pelvic exam on a patient under anesthesia during their clerkship. About half observed the informed consent process most of the time or every time. Of this group, 67% said they “never or rarely” observed someone explicitly state a medical student may perform a pelvic exam while a patient is under anesthesia. “The opinions of students were varied around what they deemed to be sufficient informed consent for pelvic exams under anesthesia,” Kaur reports.
Some students thought adding a clause to a consent form with no explicit explanation was adequate. On the other end of the spectrum, some students said a completely separate consent form for a student to perform a pelvic exam on patients under anesthesia was necessary. Overall, students favored standardized, explicit consent processes for educational pelvic exams while patients are under anesthesia. “I really admired that students expressed concerns about their own autonomy as learners,” Kaur shares.
Certain students described feeling forced to perform the pelvic exam, even though they believed proper consent had not occurred. Students wanted to honor patient autonomy, but they did not believe they had the personal autonomy to object to performing the exam. Those students reported experiencing emotional distress caused by the consent process conflicting with their personal values and professional ethical norms.
In Kaur’s view, the study’s findings signal the need for consistent trainee disclosure processes to be included in informed consent, with the goal of reducing variability across medical centers and relieving student and patient distress. Ideally, informed consent processes are created with input from all relevant stakeholders, including patients. “Ethicists play an important role in helping to contextualize policies within the ethical principles that govern modern medicine,” Kaur says.
Kaur and colleagues recommended incorporating explicit discussions with patients about pelvic exams conducted while patients are under anesthesia. These discussions should occur during consent processes for gynecologic procedures. Specifically, patients would be told about the potential for medical student involvement in these exams. “These changes would be a starting point for medical institutions to generate ethical, patient-centered policies that promote both patient and student autonomy,” Kaur and colleagues wrote.
Pelvic exams on patients under anesthesia “have always been concerning,” according to Rebecca Volpe, PhD, director of the clinical ethics consultation at the Milton S. Hershey Medical Center. In Volpe’s view, after the Supreme Court overturned Roe v. Wade, the practice is in a more problematic light. “With the right of women to bodily autonomy in the U.S. under siege, pelvic exams on people under anesthesia become even more troubling,” she explains.
Training future health professionals to conduct pelvic exams is an essential component of medical education. Patients also ought to have a right to bodily autonomy. “These two values appear to be in conflict, but they are not,” Volpe argues. “Indeed, there is a simple path forward, which should be well known to us: informed consent.”
Volpe says medical students should not be performing pelvic exams without informed consent. However, if clinicians secure high-quality informed consent, then Volpe says performing a pelvic exam on a patient under anesthesia for the purpose of learning is ethically appropriate. Decision-making capacity, information, and voluntariness are important components of high-quality informed consent.
In the context of a pelvic exam conducted while a patient is under anesthesia, an important piece of information is the fact a trainee under supervision is the one who will be performing the exam. Still, practitioners may worry few patients will agree to allow a trainee to perform such an invasive procedure. “If practitioners really worry that patients would not agree, that makes performing the procedure [without explicit consent for trainee involvement] even more morally suspect,” Volpe says.
REFERENCES
1. Goldberg E. She didn’t want a pelvic exam. She received one anyway. The New York Times. Feb. 17, 2020.
2. Kaur K, Salwi S, McNew K, et al. Medical student perspectives on the ethics of pelvic exams under anesthesia: A multi-institutional study. J Surg Educ 2022 Jun 4;S1931-7204(22)00118-0. doi: 10.1016/j.jsurg.2022.05.015. [Online ahead of print].
Incorporate explicit discussions with patients about pelvic exams conducted while patients are under anesthesia. These discussions should occur during consent processes for gynecologic procedures. Specifically, patients would be told about the potential for medical student involvement in these exams.
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