At teaching hospitals around the country, medical students routinely practice doing pelvic exams on unconscious, anesthetized female patients — often without the patients’ knowledge or consent.
Some of the nation’s 126 medical schools have forbidden the practice, but Dr. Ari Silver-Isenstadt, a Baltimore pediatrician and co-author of a 2003 paper on the topic, said the practice continues to be widespread.
According to his research, 90 percent of medical students surveyed said they had done pelvic exams on anesthetized women. He did not track how many of the patients had given permission for those exams.
Medical students on surgical “rotations” are in the operating room primarily to learn, not to care directly for the patient. For that reason, he said, “medical students who are not central to patient care should not be doing this without explicit permission. It’s a no-brainer.”
Dr. Marcia Angell, senior lecturer in social medicine at Harvard Medical School said the reason doctors don’t ask is that women might refuse — “which makes it even worse,” she said. “They have no right to use humans as tools. It’s exploitation.”
Doctors often justify having medical students perform pelvic exams on anesthetized women by saying that asking consent would take too much time, might scare patients and that patients already know medical students will be involved in their care by the sheer fact of choosing to go to a teaching hospital.
In gynecological surgery, “the exam under anesthesia is a crucial part of the procedure, it’s not separate from the surgical procedure,” said Dr. Andrea Rapkin, a professor of obstetrics and gynecology at the University of California at Los Angeles Medical Center.
Doctors must inform patients that they will be examined under anesthesia, but “we don’t specify that it is a pelvic exam,” Rapkin said. “We have no reason to specifically state that a medical student will (perform the exam)…It’s not the whole team of medical students —
it’s usually one or two.
Silver-Isenstadt’s team also found that as medical students proceeded through their training, they became less and less concerned about seeking consent, a sign that they were becoming acculturated to a medical system that, as he put it, “assumes patients are not in control of their own bodies.” In a previous paper, Silver-Isenstadt found that if asked to give permission for medical students to do a pelvic exam in the operating room, roughly half of patients would agree.
Since publication of the 2003 paper, which ran in the American Journal of Obstetrics and Gynecology many medical organizations have condemned the practice as clearly unethical.
The American College of Obstetricians and Gynecologists says that “if a pelvic examination that is planned for an anesthetized woman undergoing surgery offers her no personal benefit and is performed solely for teaching purposes, it should be performed only with her specific informed consent obtained while she has full decision-making capacity.” The Association of American Medical Colleges calls the practice “unethical and unacceptable.” The state of California now explicitly forbids it. (A UCLA spokesman said his school’s consent process meets state guidelines)
Some argue that there is simply no need to use unconscious women as teaching tools. Judy Norsigian,executive director of the Boston-based advocacy group, Our Bodies, Ourselves, noted that paid volunteers have allowed medical students to practice pelvic exams on them for years, coaching the students on how to do the exams gently and effectively.
At Harvard, the policy was changed six or seven years ago after a group of medical students objected to performing exams without express permission, said Dr. Daniel Federman who was then dean of medical education and is now senior dean for clinical teaching. Now, “a student directly involved in that patient’s care may do a pelvic exam under anesthesia if the patient’s doctor has asked her about it in advance, has introduced the student and obtained consent,” he said.
The Medical College of Wisconsin changed its policy last year to say that physicians must discuss with the patient prior to surgery the fact that a medical student may participate in a pelvic exam, and those exams must not be performed by multiple students.
At Tufts University School of Medicine, “all women coming in for obstetrical-gynecological surgery are told that if they need a pelvic exam before surgery, a medical student may be involved in that exam,” said Dr. Steven Ralston, director of the third year clinical clerkship program in obstetrics and gynecology. “But no student will be doing that unless he or she is involved in the surgery and the exam itself is necessary for the surgery. Absolutely, patients can say no.”
At the University of Massachusetts Medical School in Worcester, “every woman who is getting a pelvic exam and any man getting a genitourinary exam from a medical student has given consent for the student to do the exam,” said spokeswoman Alison Duffy.
Dr. Linda Heffner, the new chief of obstetrics and gynecology at Boston University School of Medicine, said in a prepared statement that the school does not have a written policy on this issue but is developing one. “Personally, ” she wrote, “I believe that patients should always be asked for their permission to be examined by a medical student. We need to help patients understand the importance of these examinations in the medical education process.”
Silver-Isenstadt said he became sensitized to the issue a decade ago while a student at the University of Pennsylvania School of Medicine. In the operating room one day, the surgeon did a pelvic exam on the patient — a totally appropriate and necessary pre-operative step — and then asked Silver-Isenstadt to do likewise.
“I asked, ‘Does she know I am going to do this?’ ” The surgeon said no. “I said, ‘I am really uncomfortable doing this,” — and he didn’t, though he took some grief for it.