Understanding Medical Students’ Concerns about Explicit Informed Consent for Pelvic Exams Under Anesthesia

Abstract

Background:

Medical student involvement in procedures, including pelvic exams under anesthesia (EUAs), is a fundamental part of medical education. While guidelines exist regarding informed consent for medical student participation, there is ongoing debate and uncertainty regarding the requirement and modality of obtaining explicit consent for pelvic EUAs. This study aims to explore the perceptions and experiences of medical students who do not favor an explicit informed consent process for pelvic EUAs.

Methods:

An anonymous online questionnaire was distributed to third- and fourth-year medical students at the University of Pittsburgh School of Medicine who had completed their obstetrics and gynecology core clerkship. The questionnaire included both quantitative and qualitative sections. Qualitative analysis was conducted using a mixed inductive and deductive coding approach, with key patterns, categories, and themes identified through content analysis.

Results:

Among the 201 students included in the analysis, 50 students did not endorse an explicit informed consent process for pelvic EUAs. Themes that emerged from their open-ended responses included: (1) the belief that medical student involvement is implicitly included in patient agreements at teaching hospitals; (2) the perception that pelvic EUAs are an essential first step in gynecologic surgery; (3) the view that pelvic EUAs are comparable to other medical procedures; (4) concern that explicit consent would limit educational opportunities; and (5) the belief that pelvic EUAs are not harmful or traumatic to patients.

Discussion:

The findings highlight the justifications provided by medical students who do not support explicit informed consent for pelvic EUAs. While some arguments align with previous ethical analyses, this study provides empirical and qualitative insights into students’ perspectives. The belief that patients implicitly consent to medical student involvement at teaching hospitals warrants further examination, as patient awareness and understanding may vary. The differentiation between pelvic exams and other exams under anesthesia, as well as the perception of minimal harm, should be critically evaluated in the context of trauma-informed care and patient autonomy. Furthermore, the interconnectedness of educational and surgical aspects of pelvic EUAs should be clarified in patient-physician communication.

Conclusion:

Understanding the perspectives of medical students who do not favor explicit consent for pelvic EUAs is crucial for developing and implementing consent processes. The findings emphasize the need for enhanced patient-physician communication, standardized frameworks for learner involvement, and curricular adaptations to address patient perceptions and trauma-informed care. Future research should explore these themes in larger and more diverse cohorts to inform best practices in obtaining informed consent for medical student participation in pelvic exams under anesthesia.

Introduction

Medical student involvement in procedures at academic medical centers is fundamental to medical education. All procedures and interventions in which students participate are performed under supervision of an attending physician. Many procedures are performed on awake patients who consent or assent to whether and to what extent medical students participate in their care. However, there are some situations in which consent or assent for medical student participation is less directly obtained and/or verified at the time of delivering care. These include situations in which patients are under anesthesia (e.g. surgical patients), are not conscious (e.g. sedated patients in an intensive care unit), or not able to consent for themselves (e.g. individuals who are cognitively impaired). However, patients scheduled for gynecologic surgery may not be aware that a medical student will be involved in their care, including performing a pelvic or breast exam under anesthesia¹. This has fueled recent controversy in the popular media and in politics as many as 20 states have attempted to pass legislation to regulate medical student involvement in pelvic exams under anesthesia².

One patient-centered study suggested that patients preferred that their physician disclose the involvement of a medical student in pelvic exams under anesthesia (EUA) ¹.The American College of Obstetrics and Gynecology put forth guidelines that pelvic exams under anesthesia (EUAs) performed solely for teaching purposes require specific informed consent³, however, they do not specify the manner in which this is to be done. Despite this guideline, uncertainty remains regarding both the requirement and the modality of obtaining consent for medical student participation in pelvic EUAs. A recent survey of medical students demonstrated that among students who observed informed consent practices for procedures on their ob/gyn rotation, 67% stated they did not observe an explicit explanation of the medical student role while the patient was under anesthesia ⁴. Our group found that 70% medical students surveyed in our study favor a written, explicit informed consent process for medical student involvement in pelvic exams performed under anesthesia; another 30% indicated they did not feel explicit consent for pelvic EUAs were necessary⁵.

Given persistent medical student and patient concerns regarding the current consent process, it is important to understand the perceptions and experiences of those students who do not favor an explicit informed consent process. Our prior analysis noted that students who had rotated with the gynecology oncology service during their clerkship and those who had a better understanding of the consent process were statistically more likely to disagree with implementing explicit consents for medical student involvement in EUAs⁵. In light of these unexpected findings, we wished to better understand the context and reasoning for these students’ beliefs given medical students are key stakeholders in the development and implementation of “new” consent processes for medical student pelvic EUAs.

Methods

Questionnaire and Recruitment

Development and administration of the study questionnaire, participant recruitment and eligibility were previously described ⁵. Briefly, this anonymous, online questionnaire focused on medical students’ perspectives on pelvic exams under anesthesia (EUAs) and was distributed from February to October 2020 to all third- and fourth-year University of Pittsburgh School of Medicine medical students. Those who had completed their obstetrics and gynecology (ob/gyn) core clerkship were invited to participate. In the survey, students were asked to indicate all exams/procedures performed under anesthesia that they believed require explicit informed consent. This list included prostate, rectal, abdominal, head eye ear neck throat exams, breast, musculoskeletal, and pelvic exams, along with suturing, IV placement, Foley catheter placement, intubation, and making an incision. If the student did not select pelvic exams from the provided list, they were given an opportunity to elaborate on their perspective in an open-ended response with the following prompt: “You indicated that it is not important to obtain explicit consent for pelvic exams under anesthesia. Please use the space below to tell us why.” Our analytical approach thus sought to utilize qualitative analysis techniques of open-ended responses among student participants who did not endorse the perception that explicit informed consent was important to obtain for medical student participation in pelvic exams under anesthesia.

Qualitative Analysis

For analysis of open-ended responses, a mixed inductive and deductive coding approach was used with two coders (S.E. & N.G.S) independently coding each response then meeting to adjudicate codes and develop the final codebook. Coders used N.vivo software to assist in organizing and storing the coding. Content analysis was conducted to identify key patterns, categories, and themes. After all responses were coded, the coders reviewed codes, and through discussion, noted patterns and categories that led to identifying unifying themes.

Ethical Approval

This study was approved by the University of Pittsburgh’s Institutional Review Board (STUDY19110194) and the University of Pittsburgh School of Medicine Review of Medical Student Research (ROMS) committee.

Results

Quantitative Results

Among 201 students with fully completed surveys for inclusion in our analysis, 50 students did not endorse an explicit informed consent process for pelvis EUAs. These students identified as 58% female, 68% white, 44% were in the middle-stages of undergraduate medical training, and 52% had rotated with the oncologic surgical service during their ob/gyn clerkship. Of those students who did not feel explicit consent was needed for pelvic EUAs, most felt similarly for other sensitive exams (rectal = 49/50, breast = 49/50, prostate = 49/50) as well as for other aspects of surgical care (intubation 47/50, making an incision 46/50, suturing 48/50). No student in this cohort of 50 felt explicit consent was needed for placing a foley catheter or examination of the abdomen or head-eyes-ears-nose-throat under anesthesia.

Qualitative Responses

Of the 50 students who did not endorse explicit consent for pelvic EUAs, 38 students provided text responses explaining their rationale; they were 55% male, 71% white, and 84% were at middle- or late-stages of their undergraduate medical training. Due to confidentiality concerns from a relatively low sample size from a single institution, individual participant characteristics are not revealed.

Five key themes emerged regarding these student participants’ justification for not endorsing explicit consent for pelvic exams under anesthesia. Rank-ordered by frequency of emergence, they are 1) concern this would limit educational opportunities; 2) belief that this involvement is already implied when patients consent to care at a teaching hospital; 3) view that these exams are no different from other activities involving medical students that do not require consent; 4) belief that these are non-harmful exams; and 5) view that these exams as an essential first step in gynecologic surgery.

Explicit informed consent for student involvement in pelvic EUAs would limit educational opportunities

Six students expressed a fear that obtaining explicit consent would limit their educational opportunities as they believe that more patients would opt out of allowing students to participate. Two exemplary quotes encapsulate this sentiment: “Ideally we’d get explicit consent for medical students to participate in care at all, but too many patients would probably opt out of involving medical students if they had an explicit choice” and “Requiring informed consent for medical students would further limit our exposure to an already under exposed part of the physical exam.”

Pelvic EUAs by students are part of implied consent process at a teaching institution

Of the 38 responses, 20 students expressed the belief that patients implicitly consent to medical student involvement in their care when they consent to treatment at a teaching hospital, and that performing pelvic EUAs is just one of the many things to which they have consented. Several responses also expressed the sentiment that students are an essential member of any medical team at a teaching hospital and thus their involvement in patient care is implied. Quotes to this effect include: “Patients are reminded frequently that this is a teaching institution, which means that they will receive the highest quality care but also part of the care will be provided by trainees” and “It is a teaching hospital: attendings teach and medical students practice/learn.”. In one student response, this belief in an implicit agreement for student involvement in seeking care at a teaching institution was interpreted as a requirement: “If anything, the “fix” in my opinion is making sure people understand they are at a teaching hospital and professional students may participate in their care. If they don’t want that, they can opt out”.

Pelvic EUAs are similar to other medical procedures

Seven students also endorsed the idea that performing a pelvic exam under anesthesia is comparable to assisting with any other medical procedure. Students responded that the pelvic exam under anesthesia should be treated no differently from any other aspect of medical student involvement in patient care: “They don’t sign a consent form to have a medical student at their bedside in the morning on rounds. They don’t sign a consent form for an attending surgeon to point out structures during surgery or to manipulate arteries, nerves, or other structures so you can see them.” As one student wrote, “[the pelvic EUA is the] same as medical students having hands in body cavity during any other procedure.”

Pelvic EUAs are not harmful or traumatic to patients

Five students endorsed the belief that pelvic exams under anesthesia are neither harmful nor traumatic to patients and, consequently, explicit informed consent should not be mandatory. As one student noted: “Informing an awake individual of your training status and seeking explicit consent for involvement is a considerate gesture, but obtaining explicit consent for involvement in a consented procedure that poses minimal threat of harm in an unconscious individual should not be mandatory.” Another stated: “Because you’re under anesthesia, it isn’t traumatic in any way.”

Pelvic EUAs are an essential first step in gynecologic surgery

Sixteen students also stressed the importance of differentiating between pelvic exams under anesthesia that were performed solely for educational purposes without relevance or connection to the scheduled surgical procedure and pelvic exams under anesthesia that were necessary for surgical preparation: “It was expected that as a part of the surgical team I understand the size, location, and quality of the mass we were attempting to remove both from radiographic images and from physical exam, which included a bimanual exam. It seemed like an appropriate part of providing patient care rather than an exploitative opportunity to ‘practice’”. Students believed that the pelvic exams they were asked to perform on patients during their obstetrics and gynecology rotation were clinically relevant and not simply an educational opportunity.

Discussion

Our findings elucidate the beliefs of students who did not endorse requiring explicit consent for medical students’ participation in pelvic EUAs. Most of the justifications we noted were similar to those reviewed in prior ethical normative analyses but not previously empirically or qualitatively studied — specifically, concern for negative impact on medicine training, implicit inclusion of these exams in the context of receiving care at a training hospital, and the belief that the pelvic EUA does not differ from other procedures performed by students under anesthesia^6,7. It is important to understand these perceptions in order to address student concerns around consent, better incorporate these conversations into medical education curricula around consent, and continue to uphold patient autonomy in the realm of medical education. Furthermore, it is important to consider the potential influences of gender, socioeconomic status, and ethnicity on the development of the beliefs examined below, as the study demographic was predominantly white and male.

A key theme from students’ open-ended responses that is also reflected in the literature is the belief that patients implicitly consent to medical student involvement in their care when they consent to treatment at a teaching hospital⁸. From a medical-legal standpoint, medical student involvement in patient care at academic teaching hospitals is deemed generally permissible since most patients sign a consent-to-treat document that includes language regarding learner involvement in their care. Nevertheless, patients may not know what to expect regarding learner involvement in their care. In one study, patients believed that students were primarily observers in the clinical environment and frequently confused medical students with other trainees, like interns and residents¹. Further, there are multiple factors influencing where patients seek care and it is likely an oversimplification to posit that patients intentionally select a teaching hospital. The sentiment that patients who do not agree to trainee participation can seek care elsewhere overlooks the various barriers (i.e. location, proximity, transportation, insurance coverage, etc.) that may limit patients from doing so if they did not want medical student involvement in their care. Furthermore, given that academic medical centers provide the majority of care to medically underserved populations⁹, it is of the utmost importance in serving the medically-vulnerable that the role of learners be disclosed, especially for exams under anesthesia that patients may not be aware that a learner is performing. It may also be logistically impossible at an academic hospital for patients to receive care solely from attending physicians. However, this should represent an opportunity to enhance patient-physician communication and promote patient autonomy by providing transparency regarding the role of individuals on the care team. We propose that, when possible, supervising physicians use a standardized framework to normalize the involvement of learners on their care team and encourage a dialogue with patients on this topic. At the crux of this conversation must remain the importance of ensuring patients understand who may be involved in their care and feel empowered in asking questions when necessary.

Further, two related themes with historical corollaries were raised including the belief that performing a pelvic exam under anesthesia is comparable to assisting with any other medical procedure¹⁰ and the belief that pelvic exams under anesthesia are neither harmful nor traumatic to patients. The assumption that the pelvic exam is comparable to and no more harmful than any other exam under anesthesia is physician-centered and may not fully consider the experiences of patients, who have indicated that the pelvic exam under anesthesia is different and more harmful than other exams when unconsented¹¹. The differentiation between pelvic exams and other exams has been previously termed “stigmatization of female anatomy”, an idea that pushes back on the legislative invasion of women’s health. While legislative encroachment on the patient-physician relationship is important for physicians to combat, it is equally important to create practices that prioritize patient autonomy and value patient perceptions of their care. Similarly, while physical harm from pelvic exams under anesthesia may seem minimal and equivalent to other exams, the emotional and psychological harm that may come from patients perceiving an pelvic exam without consent is a significant violation of the tenets of trauma-informed care. This discrepancy offers yet another opportunity to enhance trauma-informed medical education curriculums by incorporating more nuanced conversations around harm and how seemingly benign interventions from the viewpoint of physicians may deteriorate the patient-physician relationship if not properly communicated.

Finally, we observed a tendency of medical students to differentiate pelvic exams under anesthesia performed solely for educational purposes from those performed for surgical preparation. While medical students clearly specified that exams performed solely for educational purposes do require explicit informed consent, some indicated that if the exam is required as part of planning for the procedure, then they, as a member of the surgical team, should be able to perform the exam without obtaining explicit consent. At academic hospitals, it is almost impossible to disentangle this mutual exclusivity. That is, a medical student may perform a bimanual exam and insert the speculum under the direct supervision of an attending physician who may then verify positioning and important landmarks but not perform an entirely separate and independent exam. In this instance, the pelvic EUA is both an indicated part of the surgery and is educational for the medical student. Given that these roles are difficult to disentangle for those unfamiliar with the logistics of the clinical setting and healthcare delivery, it may be difficult to capture these nuances within the confines of legislation aimed at ensuring explicit informed consent processes for medical student pelvic EUAs. Such legislation may have unintended consequences of limiting student’s opportunities to learn important physical exam skills that they are then able to apply to other patient contexts outside of the operating room. For example, an Emergency Medicine physician must be able to efficiency and competently perform a pelvic exam for someone presenting with vaginal bleeding to provide necessary care. Pelvic exam competency is relevant and necessary in almost every field of medicine, and all medical students, regardless of their intended specialty, should be adequately trained on these skills. In balancing these priorities, what remains important is protecting the role of learners on the care team as we continue to nurture future generations of physicians and maintaining transparency regarding the role of learners in conversations with patients to protect patient autonomy. Clear patient-physician communication, and not legislation, regarding the role of various team members is thus essential in achieving a truly informed consent process.

Conclusion

In conclusion, by analyzing factors which may influence student perceptions of informed consent and giving voice to those who do not endorse explicit informed consent for pelvic EUAs, we identified multiple themes that can be used to inform future research, advocacy efforts, and educational interventions to improve patient-physician communication and uphold patient autonomy in the realm of medical education.

Highlights.

• The study examined medical students’ concerns over explicit informed consent for pelvic exams under anesthesia.

• Five key themes emerged from medical student responses regarding their rationale for not endorsing explicit consent.

• Some of the key themes reflect those existing in the literature.