Canadian Press
Tuesday, March 11, 2003

PHILADELPHIA (CP) - Some of the leading U.S. medical schools have abandoned a little-known, decades-old practice of letting students perform pelvic exams on women without their consent while they are under anesthesia.

The schools are asking permission first. Previously, these institutions had routinely brought in students - sometimes as many as three or four - to conduct pelvic exams on unconscious women just before their gynecological surgeries and often without their consent.

Changes have taken place in the last five years after complaints from students who felt the exams without consent were unethical.

"My problem was that if they found out about it, they might be really upset, and it was really only being done for my benefit," said Dr. Ari Silver-Isenstadt, who refused to examine anesthetized women as a student at the University of Pennsylvania. "I felt like I would be violating their trust."

In Canada, the troubling little secret came to light two years ago when the British Medical Journal published a survey of University of Toronto medical students. Nearly half complained they had been asked to perform unethical practices during their education, such as performing pelvic or rectal xaminations on unconscious patients who had not consented to the procedure. At the time, the director of ethics for the Canadian Medical Association admitted similar practices were probably used at other medical schools in Canada. But Dr. John Williams said they should not be. "Practising skills like rectal examinations on those who are unconscious at the time is really, I think, off the scale as to what's permissible. It may happen, but I think that would be not very defensible," Williams said at the time.

Students at Harvard Medical School also raised objections in the mid-1990s. Dr. Daniel Federman, senior dean for clinical teaching at Harvard, said the complaints led to a new policy under which surgical patients had to give consent for a pelvic exam for training purposes. In addition, the students had to be part of the medical team. "Very few patients decline. And when they do, we honor it," Federman said.

At the medical school of the University of California, San Francisco, complaints by students in the late '90s led to a line being added to patient consent forms, specifically noting that women having gynecological surgery may be given a pelvic exam while they are under anesthesia. Typically, the surgeon performing the operation conducts an exam to confirm the problem to be corrected by surgery. Dr. Patricia Robertson, UCSF's director of obstetrics and gynecology clerkship, said students have also been directed to meet with the patient before each operation and explain how they will be involved in their care. "The students, I think, were most upset because they felt there were students lining up in the operating room doing pelvic exams, who really had nothing to do with the patient," she said.

Most medical students today learn the basics of the pelvic exam by practising on paid volunteers but eventually need to move on to real patients. Anesthetized women are the perfect subjects, doctors say, because they are relaxed and unable to feel the sometimes painful mistakes of novice examiners.

Consent is still far from a universal practice.

At the Washington University School of Medicine in St. Louis, patients are told that students will be part of their care team, but aren't specifically told the treatment could include a pelvic exam for educational purposes.

There are similar policies at the University of Pennsylvania and the Johns Hopkins School of Medicine. "I don't think any of us even think about it. It's just so standard as to how you train medical students," said Dr. Jessica Bienstock, residency program director at Johns Hopkins. Many students, however, appear to disagree: 70 percent surveyed at Philadelphia-area hospitals in 1995 before they completed an obstetrics and gynecology clerkship said it was important to ask women for consent, according to a study published last month in the American Journal of Obstetrics and Gynecology. Silver-Isenstadt, one of the study's authors, said that number dropped to 51 percent among students who had completed a clerkship, which he views as evidence of a cavalier attitude toward patient privacy.

Dr. Michael Gregory, a Boston public-health physician who objected to the exams when he was a third-year student at Tufts University School of Medicine, said that while studies show most women will give their consent, doctors are afraid to ask. "It's this paternalistic, patronizing view that the doctors know best.... We underestimate people's incredible charity and their willingness to let us train," he said. "But I think that at a gut level, doctors understand that if they actually told patients that this was happening without their consent, people would be outraged."


Posted By: Rachel
Women's Health News
Saturday, March 03, 2007

The New England Journal of Medicine has a perspective piece by Adam Wolfberg in the current issue, "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 anesthetized 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 found that only 51 percent of those who had completed an OB/GYN clerkship thought consent prior to pelvic exam was "very" or "somewhat" important - 24 percent were "neutral," 15 percent found consent to be "somewhat unimportant," and 9 percent 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 percent stating it was "very" or "somewhat" important - still far short of the 100 percent 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 that "more than 80 percent 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]

Posted by Rachel at 3/03/2007


I equate this practice of pelvic exams being performed on women without the patient's consent, whether conscious or unconscious, as a form of gynecological rape. As a woman and a midwife, I find the practice appalling and "informed consent" should ALWAYS be obtained before ANY procedure, whether as a part of medical care or as part of educational training.

My feelings on this matter are compounded by the experience I had as a first time pregnant woman... my health care practitioner, without my permission or prior warning, brought in 6 medical students to observe a pelvic exam on me while I was conscious on the exam table. I was so mortified that I pulled the exam sheet over my head in embarrassment and cried. I was a woman with a past history of childhood abuse and I was also a survivor of violent sexual rape and years of domestic abuse. These experiences has influenced my midwifery practice in that I get permission for anything I do or plan to do when it comes to touching another person's body. No one has the right to touch your body without direct permission from you and with guidelines you put into place that you are comfortable with.

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