Pelvic Exams Done Without Consent
This Article (Time to End Pelvic Exams Done Without consent) was sent to me by a friend for a response, many moons ago.
It sat in my mailbox for a long time, and I wrote a bit here and there. I thought about it on my surgery rotation. I got busy and never finished a response, until now. The article raises some legitimate concerns; while I could try and refute point-for-point, I think I’ll just give a more broad opinion:
In my years of training, I can say I have not witnessed medical students ‘parading around’ for the purposes of practising a gyne exam, nor participated in it. I think the article exaggerates as to the prevalence and the callousness of this act. Other bloggers have commented that they felt some relief that this wasn’t just happening to random patients, but that it was restricted to gynecological surgery patients who had consented to their surgery. Some of the comments on that blog indicate that up to 12 students do such an exam. Honestly, even one extra person in the OR can make it too crowded, I can’t imagine 12 people or an Attending who would promote such a thing. Even then, I have never done such an exam when I wasn’t a member of the surgical team, nor would I think it appropriate. No one could justify a Gyne exam on a patient who was not in for a Gyne concern. Period.
We were extremely fortunate at The University of British Columbia (UBC) to have midwives and nurses volunteer to let us practice on them while they gave us feedback about their psychological and physical comfort. It was a valuable experience to have someone who wasn’t afraid to correct you if you did something wrong. Then, over years of rotations in Family Practice, ER, and Obstetrics/Gynecology, there were many women that I verbally consented for a pelvic exam that I then performed. It actually isn’t that difficult a skill to learn if you have a patient who is relaxed, patient, and trusting. The ones who weren’t, usually asked if my Attending could do the procedure. Sometimes we reached a compromise where I would do the exam and the Attending was standing by to jump in if I was utterly terrible at the procedure. I have not done a million of these, yet, but I am gaining proficiency and have been told by many patients that it wasn’t as scary or uncomfortable as they feared, and that I put them at ease.
The point where I get a bit worried is if I see something on a speculum exam, or feel something on a bi-manual exam, that doesn’t seem right. Then, I have to figure out what it is exactly, and though I know it’s “abnormal” I don’t have a lot of past experience (of non-normal exams) to call on. A lot of ‘abnormal’ things on a gynecological exam wind up in the Operating Room.
In that environment, I have done gyne exams on anesthetized patients where I have not formally consented them. In all of these cases, the patient has signed a form allowing the doctor and any staff/learner/etc. to be involved in their care, as well as for their specific procedure and any other reasonable related procedure deemed to be needed in the process. Before signing this, the risks, benefits, and alternatives to the procedure are discussed. Granted, often people don’t read this form and don’t explicitly know that a learner could be present during their surgery, let alone doing anything invasive. The form does not say that a pelvic exam may be performed, but it is said to be entailed within those ‘reasonable related procedures.’ Without a person saying “yes, I consent to you performing a pelvic exam while I am under anesthesia,” is a pelvic exam rape?
I do lots of consented pelvic exams in the office and would have no trouble asking someone for permission to examine them under anesthesia. Problem is, with the schedules of residents, we may not always see the patient before they are asleep in the Operating Room. Ideally I would verbally ask, but it is often a technical impossibility due to being occupied with ward patients or consults until the moment of scrubbing in. Writing that now, it doesn’t sound like a great excuse. Often, the surgeon will say “I have a resident working with me today” but not ask for explicit consent that either they (the surgeon) or I (the resident) be allowed to examine the patient under anaesthesia. It is implicit in the fact that they are requesting to have this gynecological concern remedied, and it is also documented on the written consent, and some would argue that that is sufficient. Legally it is apparently acceptable but whether it is ethically justifiable is the real question. The University of Toronto has a clear policy on this; they do state that
Consent for pelvic examination by medical trainees is contained within consent for a surgical procedure.
It is very normal for the attending surgeon to examine the patient right before she operates – this prevents error (“oh, it was on the left side?”), and helps to direct the surgery and can sometimes even change the approach. Where I am assisting in a surgery, I will be invited by the gynecologist to feel the tumour/mass/etc which means a pelvic exam. However, I will not examine if I know there is nothing to find because it will not assist my role in the surgery. I’m not there to practice a normal exam and there’s no benefit to the patient to do an exam. Usually, I do accept the invitation or even ask the surgeon if I may examine the patient, if I know that she will have findings. This way, I know what we are ‘surgerizing’ and I can also take this experience back to the clinic to better my ability to recognize and differentiate the ‘abnormal’ stuff. There is enormous learning value in feeling a cystocele, ‘bulky uterus,’ ovarian mass, or the like. I am not advocating that people do the exam simply to learn about pathology, but it is a great benefit of an exam that is necessary for any member of the surgical team to perform in order to safely and effectively complete the surgery. I am totally against random students who are not involved in a case being encouraged to do a pelvic exam unless the patient is conscious and gives consent to that individual.
Overall, when it comes to examining patients under anesthesia in the current system, I leave it to each medical student and each resident to decide what is appropriate or what isn’t. I would be disturbed if someone I knew invasively examined me (conscious or unconscious) and would expect that a person I knew would decline the option unless it was an emergency or they were the only person who was capable of doing some necessary procedure [this happens in small towns!]. I am okay with a stranger examining me, because I know the compassion and eagerness to learn of healthcare students, and I know that allowing them to examine me would make it easier on the next person who may be less comfortable with the idea.
Learning a ‘normal’ exam can easily be achieved in many venues. The value of examining abnormal stuff which winds up at surgery is tremendous but still can’t outweigh the harm of an unconsented, invasive exam. There’s no reason the person consenting a patient for a surgery couldn’t explicitly say:
Part of the procedure may involve a pelvic exam (before or during anesthesia) performed by the surgeon and any learner or assistant under their supervision who is part of the surgical team; this examination would be done in order to select the appropriate technique and instruments for the surgery.
One benefit of this is that the learner (if present) will become familiar with abnormal presentations so that they can better recognize and treat them in the future, though this is not the reason an exam would be undertaken by the learner.
The right thing to do is to explicitly ask the patient every time, just before the examination. Some (like me?) may argue that it isn’t always practical or possible, but certainly we can all agree that more effort should be made to make the process transparent and the consent clear. Honestly, though, if you cannot trust a medical student to make careful decisions and to show respect and preserve dignity in all that they do, then you cannot trust them to be a doctor.
(and just FYI, the same basic thoughts apply to male urological procedures, breast lumps, bowel cancer, broken bones, and everything else. We’ve got to examine it before safely cutting it out/drilling into it/joining metal to it/etc., you know?)
Am I full of it? Too paternalistic? Too focused on the need for learners to learn? Let me know. Posts like these are to open up discussion, not for me to pretend I know everything!