Consent for Pelvic Examinations Under Anesthesia by Medical Students: Historical Arguments and Steps Forward

Abstract

We provide an overview of the issue of specific consent for pelvic examinations under anesthesia performed by medical students. Arguments that have historically been made against requiring consent for such examinations are reviewed and refuted. The implications of requiring consent for examinations under anesthesia are discussed as they relate to patient autonomy, medical student education, and society at large. Finally, we outline a solution and offer sample language that balances the interests of patients, learners, and society.

Précis

Obtaining specific informed consent for examinations under anesthesia is in the best interest of patients, medical students, physicians, and society.

As physical examination is a cornerstone of high-quality clinical care, it is vital that future generations of physicians are afforded the opportunity to hone their knowledge and skills. While patients are awake and able to make decisions, obtaining consent for examinations is routine. However, procuring consent from patients is no longer possible following induction of general anesthesia in the operating room. While medical students rarely pause out of concern when examining the cranium during a neurosurgery case, the patella during an orthopedic surgery, or the abdomen during a general surgery case, performing a pelvic examination on an anesthetized woman may pose additional complexities for both the patient and the learner. In fact, a survey of 75 female patients in 1988 reported that all patients thought permission should be sought for a medical student to perform an examination under anesthesia, 41% felt that consent should be obtained in writing, and some stated they would feel “physically assaulted” otherwise.¹ Another survey of 102 women in 2010 found 72% of women expected to be asked for explicit consent before a medical student performed an examination under anesthesia.² Additionally, learners have voiced discomfort at being asked to perform such examinations without specific consent.³

Thus, there exists a complex balance between protecting patients, preventing distress for learners, and ensuring adequate education. Primary importance must be given to respecting a patient’s right to bodily integrity and ensuring that she is able to make autonomous decisions regarding who examines her. Given this ethical imperative, national policy organizations and several state legislatures have offered guidance. In 2011, the Ethics Committee of the American College of Obstetricians and Gynecologists (ACOG) stated, “pelvic examinations on an anesthetized woman that offer her no personal benefit and are performed solely for teaching purposes should be performed only with her specific informed consent obtained before her surgery.”⁴ More recently in March 2019, the Association of Professors of Gynecology and Obstetrics (APGO) recommended “…when the patient is under anesthesia, [learners] should only perform pelvic examination for teaching purposes when the pelvic exam[ination] is explicitly consented to…”.⁵ To our knowledge, as of June 2019, California, Hawaii, Illinois, Iowa, Maryland, Oregon, Utah, and Virginia have outlawed examinations under anesthesia without specific consent, while additional states have proposed similar, pending legislature. The language in these statutes varies. Illinois requires all healthcare professionals, including students and residents, to inform patients of their profession when providing care.⁶ Some states (i.e. California, Iowa, Maryland, Oregon, Virginia) simply specify that pelvic examinations on anesthetized female patients cannot be performed without informed consent, but do not provide clarity regarding the mechanism of informed consent.^7–11 Some states (i.e. Hawaii) specify that such consent can be either verbal or written.¹² Other states (i.e. Utah) require a specific written form with the option to consent for a pelvic examination for diagnosis and treatment separately from the examination by a student or resident for education or training purposes.¹³ Ramifications of not complying with these state laws generally include professional discipline by the licensing board or being charged with a misdemeanor.^8,10

Such protections are both for the patient who is vulnerable in the operating room and for the student’s right to learn without experiencing moral distress. However, the implementation of these policies has proven complicated, given the potential ramifications for students’ educational experience, implications for informed consent in other aspects of surgery, and ongoing stigma toward female genitalia. We first review several arguments made historically regarding the lack of specific consent for an examination under anesthesia performed by a medical student. Second, we discuss the potential implications of these national organizational policies and state laws at the patient, societal, and medical education levels. Finally, we offer a possible solution in which to balance these varied goals in a manner that is easily adoptable in clinical practice.

Historical Arguments Against Specific Consent

Implied Consent

A common argument made against requiring specific informed consent for an examination under anesthesia performed by a medical student is that consent is implied when patients receive care at a teaching hospital, since they are aware that medical trainees will be involved in their care. This argument, however, is built on the assumption that the patient is awake and conscious. As an example, if a medical student enters an examination room and introduces themselves to the patient, she is free to decline student involvement in her care. If she does not state an objection, consent to speak with the medical student is implied. If a pelvic examination is indicated, the patient can both be asked and decline permission for the student to perform the pelvic examination under supervision. However, the majority of patients do not have extensive knowledge of the steps involved in gynecologic surgery. Therefore, consent cannot be implied as many patients do not have pre-existing knowledge of and thus, the ability to decline medical student involvement in specific parts of the procedure.¹⁴ In addition, patients may not intentionally seek care at teaching hospitals in many scenarios, such as in emergencies, for geographic convenience, or due to insurance coverage.¹⁵

Therapeutic Involvement

Some have argued that while consent may not be implied by virtue of obtaining care at a teaching hospital, the patient has consented to the student’s involvement by signing preoperative consent forms.¹⁵ However, such authorizations are made for therapeutic benefit to the patient, not for educational purposes. While the surgeon may perform a preoperative pelvic examination to assist in the operative strategy, it is unlikely that the same can be said of an examination by a medical student.^3,14 Therefore, consent for general medical student involvement in therapeutic care cannot be extrapolated to a solely educational procedure such as an examination under anesthesia by a medical student.

Slippery Slope

Another common argument against specific consent for an examination under anesthesia by a medical student is that the preoperative examination is simply one step of a gynecologic surgery and therefore, requiring specific consent for an examination under anesthesia would mean that specific consent should be obtained for every procedure that a medical student may perform such as cutting suture, retracting, or manipulating the uterus in laparoscopy. Doing so is not feasible in terms of foreseeing every step a student may perform, for the practical consideration of time involved, and as doing so may overwhelm patients and actually detract from achieving truly informed consent of the goals and risks of surgery. However, medical student assistance with the surgery offers the patient therapeutic benefit, and therefore would be authorized as discussed above. Furthermore, during the consent process and for both legal and billing reasons, the attending physician confirms that she will supervise the entire procedure – including such decisions as to whom cuts suture and where retractors are placed. Most importantly, while gynecologists see the examination under anesthesia as simply one part of the surgery to be performed, to patients, the examination under anesthesia is perceived as a distinct entity among other steps of gynecologic surgery and therefore, patients may expect to be asked for specific permission.²

Potential Implications

Psychosocial Considerations

Although obstetrician-gynecologists may see a pelvic examination as equivalent to any other physical examination, it can seem invasive, even intimate to the patient, depending on her individual background, beliefs, and life experiences. There are numerous psychosocial considerations pertinent to this discussion that influence how a woman perceives her genitalia, and how she would feel about a student performing an examination under anesthesia. Such factors may include a woman’s sexual orientation, gender identity, religious beliefs, cultural background, marital status, parity, history of sexual trauma, and life experiences. Sexual violence is prevalent in the United States with one in five women having been raped and 43.6% of women experiencing some form of contact sexual violence in their lifetime.¹⁶ Trauma-informed care is an evidence-based framework that is guided by the assumption that individuals are more likely than not to have experienced trauma.¹⁷ Obtaining specific consent, then, is practicing trauma-informed care to both understand the impact of trauma and avoid re-traumatizing patients.¹⁸ However, it is incorrect for health care providers to automatically assume a woman feels differently about her body due to a history of sexual trauma, gender identity, or religiocultural background. It is imperative to respect patient autonomy and avoid making paternalistic decisions on behalf of the patient in order to “protect” her. While we must be aware of and sensitive to psychosocial factors, as professionals, we must also be cognizant of our own biases and assumptions we make about our patients.

Stigmatization and Exceptionalization of Female Genitalia

The increased attention by the media and society at large on female pelvic examinations but not, for example, on prostate examinations under anesthesia, can be seen as continued stigmatization of female anatomy. Given the prevalence of exceptionalism, mysticism, and misinformation regarding the female body, obstetrician-gynecologists have a responsibility to destigmatize female genitalia. However, this responsibility is carried out through education and advocacy at the systems level, not in the operating room at the level of the individual patient. The fact that some states have framed their legislation as applying only to female examinations under anesthesia is problematic on several fronts. It singles out women as fragile and needing protection. All people, regardless of sex, should be able to explicitly consent to examinations under anesthesia. While we are troubled by other legislative encroachments into women’s health, the intent of those regarding examinations under anesthesia differs from others. Whereas anti-choice laws prevent a woman from exercising her autonomy, laws requiring specific consent for examinations under anesthesia ensure that a woman has that right. Though much work remains to be done to decrease the stigma and exceptionalism associated with female genitalia, the individual autonomy of the patient must be respected and upheld.

Training Future Physicians

As a specialty, we need to ensure future physicians are proficient at performing pelvic examinations and the examination under anesthesia may offer a superior learning experience for ascertaining anatomy and pathology due to the relaxation of pelvic musculature. Though many medical students employ standardized patients to teach pelvic examination skills to students, the examination under anesthesia continues to offer a distinct learning benefit given the opportunity to evaluate anatomy with pathology requiring surgery as well as the chance for the teacher to speak more candidly during the teaching process. Some educators fear that if specific consent for a medical student to perform an examination under anesthesia becomes mandated, too many women would decline and students would miss out on such learning opportunities.^3,14,15 While data are largely unavailable on this question, there is some literature to the contrary. In the survey detailed above of 102 women, 62% reported that they would consent to medical students performing an examination under anesthesia if asked beforehand. Only 14% of respondents said they would refuse, 5% stated they would not consent if a male medical student were performing the examination under anesthesia, and the remainder were unsure.² We wholeheartedly believe that all physicians should be trained in performing a pelvic examination. However, achieving this goal is a responsibility of our profession – and not a burden to be passed on to the individual patient.

Proposed Solution

Responsibility for specific consent for a medical student examination under anesthesia rests with the attending physician as the attending physician holds the primary clinical, ethical, and legal relationship with the patient. We believe that this discussion of medical students’ involvement with examinations under anesthesia during surgery should be a part of the informed consent process for all procedures in which a patient will be anesthetized, regardless of sex and including non-gynecologic cases. In so doing, the exceptionalization of the female genitalia is minimized.

Specific consent for a medical student examination under anesthesia should be obtained, ideally during the informed consent discussion at the preoperative office visit. During this process, the key steps of the surgery should be listed, purposefully mentioning the examination under anesthesia step. We recommend an explicit statement that medical students, residents, and fellows (as appropriate) will be involved in each step of the procedure and patient’s care, including the examination under anesthesia. Patients should also be informed that the specific medical students, residents, and fellows involved in the surgery and performing the examination under anesthesia will introduce themselves to the patient prior to surgery. For example, this conversation could be structured as follows, “The procedure I recommend is an exam under anesthesia, dilation and curettage, and hysteroscopy. As this is a teaching hospital, medical students and residents will be involved in all aspects of your surgery, including the exam under anesthesia, with your consent. Their role is both to ensure you receive excellent clinical care as well as to further their education for future patients. As the attending surgeon, I will supervise your surgery and their participation in your care. The day of surgery, the medical student and resident that will be involved in your case will introduce themselves to you in the preoperative waiting area. Do you have any questions regarding the role of students and residents in your surgery? The specific steps, risks, benefits, and alternatives of your surgery are as follows…” As many patients do not fully read or have the health literacy to fully understand medicolegal forms, it is important that physicians have a conversation about the risks, benefits, alternatives, and steps of the procedure, specifically including the examination under anesthesia, as to give the patient a chance to ask questions as well as decline.

In addition to such a verbal discussion with the patient, written consent for a medical student to perform an examination under anesthesia should be obtained as well. This could be achieved through inclusion of the examination under anesthesia as a specific component of the surgery (e.g. examination under anesthesia, dilation and curettage, hysteroscopy on the procedure line of the consent form) or as a specific section on the consent form where a patient signs her agreement (e.g. a checkbox for the patient to explicitly denote “I consent to an examination under anesthesia by medical students, residents, and fellows for diagnostic, therapeutic, and educational purposes”). However, informed consent is a process, not simply a document. Written consent should indeed be included as part of the evolving policy on this matter, but should be in addition to – not a replacement of – the verbal discussion of the examination under anesthesia.

On the day of surgery, in the preoperative suite prior to the administration of medications that can alter mental status, the medical student(s), resident(s), and fellow(s) assisting with the surgery should meet the patient, review the consent, and provide an opportunity for questions, as is standard practice. During this time, the medical student (or other trainee) should reconfirm permission for the examination under anesthesia, but this should not be the primary mode of consent. Students who are not introduced to the patient before surgery should not perform an examination under anesthesia. We feel that it is inappropriate for patients to be confronted with this decision for the first time right before surgery (for routine, scheduled cases – emergent cases notwithstanding), as patients may feel coerced into consenting with the student present in front of them. With the exceptions of emergencies, the patient deserves to know the key aspects of the surgery – including the presence of a medical student performing an examination under anesthesia – prior to the day of surgery, as well as a conversation refreshing her on the information before the procedure.

This solution balances the varying perspectives and interests of patients, medical students, and physicians. This process satisfies ethical and legal requirements for general informed consent, as well as specific consent for an examination under anesthesia by a medical student. The conversation is feasible regarding a physician’s time constraints. It informs a patient that, if present, it is standard for a medical student to perform an examination under anesthesia, though she may decline this examination if she so chooses. This solution avoids the slippery slope of disclosing every possible step a medical student could potentially be involved with in the operating room. Further, listing the examination under anesthesia as a standard step of the gynecologic procedure normalizes the practice and avoids stigmatizing female pelvic examinations. Our recommendation that discussion of medical student involvement for examinations under anesthesia in all surgical procedures avoids singling out female pelvic examinations, and acknowledges the right of all patients to decide who examines their body. Our proposed solution preserves both the ability of students to learn and the societal benefit of training future physicians, without sacrificing informed consent or patient autonomy. This balances the duty to care for patients with the duty to teach future physicians.

Steps Forward

The nuances of clinical practice sometimes make the delineation between therapeutic and educational involvement on the part of students less than crystal clear. Thus, we caution physicians to employ a broad definition of examinations under anesthesia by medical students given the relevant policy and laws. We hope that medical schools and training programs will continue to study the optimal manner to obtain specific consent for examinations under anesthesia. We also encourage medical school administration, medical student clerkship directors, as well as residency and fellowship program directors to implement clear policy at their institutions. Students should be informed of their hospital’s policy at the beginning of the clinical rotation to reduce distress and ensure adherence. Finally, for consistency and clarity, it is optimal that national leadership bodies such as APGO, Council on Resident Education in Obstetrics and Gynecology (CREOG), and the Accreditation Council for Graduate Medical Education (ACGME) create a framework to guide this process. Adoption and enforcement of a policy for obtaining specific consent is in the best interest of patients, medical students, physicians, and society.