Aligning patient and physician views on educational pelvic examinations under anaesthesia: the medical student perspective

Abstract

Recent media articles have stirred controversy over anecdotal reports of medical students practising educational pelvic examinations on women under anaesthesia without explicit consent. The understandable public outrage that followed merits a substantive response from the medical community. As medical students, we offer a unique perspective on consent for trainee involvement informed by the transitional stage we occupy between patient and physician. We start by contextualising the role of educational pelvic examinations under anaesthesia (EUAs) within general clinical skill development in medical education. Then we analyse two main barriers to achieving explicit consent for educational pelvic EUAs: ambiguity within professional guidelines on how to operationalize ‘explicit consent’ and divergent patient and physician perspectives on harm which prevent physicians from understanding what a reasonable patient would want to know before a procedure. To overcome these barriers, we advocate for more research on patient perspectives to empower the reasonable patient standard. Next, we call for minimum disclosure standards informed by this research and created in conjunction with students, physicians and patients to improve the informed consent process and relieve medical student moral injury caused by performing ‘unconsented’ educational pelvic exams.

Present and future

“…3 It also contains a critical appraisal of the most recent (2016) WHO guidance document on the management of ethical issues during an infectious disease outbreak. 4 This June issue of JME also addresses several important clinical ethics issues: covert administration of medication in food, 5 educational pelvic exams under anesthesia, 6 consent to cancer screening, 7 care of critically ill newborns when the birth mother is unwell, [8][9][10] and ethical considerations related to recruiting migrant workers for clinical trials. 11 Perhaps what is most unique about this issue is its Feature Article and associated commentaries.…”

Should medical students perform pelvic exams on anaesthetised patients without explicit consent?

“…suppose that in the same circumstances one might legitimately say to a patient that ‘this medical student will be assisting today’ or that ‘this medical student will be performing a pelvic examination while you are under anesthesia’ and still validly secure their ‘specific informed consent’. 4…”

“…3 It can also be difficult as refusal may hinder relationships with senior clinicians and reflect poorly on the student's commitment to learning. 4 As a result, medical students are often left feeling powerless, shameful and morally distressed after performing exams they know are unethical. 5 Moral distress is both intrinsically and extrinsically harmful, as it is an extremely negative experience associated with undermining ones integrity which can lead to burnout, depression and anxiety.…”

“…Salwi et al suppose that in the same circumstances one might legitimately say to a patient that 'this medical student will be assisting today' or that 'this medical student will be performing a pelvic examination while you are under anesthesia' and still validly secure their 'specific informed consent'. 4 It seems obvious to us, however, that the notion of 'specific informed consent' is clear and that it requires nothing less than a complete and accurate account of what one is seeking permission to do. When medical students are planning practice pelvic exams on anaesthetised patients what is being undertaken is an additional physical intervention that would not otherwise occur.…”

“…Over the past 3 decades, there have been ongoing debates regarding the performance of pelvic exams by medical students on anaesthetised patients for their own educational benefit. [1][2][3][4] A recent focus of such debates has been on the way in which informed consent is sought from patients. 3,5 As a requirement of their degree, medical students must achieve a range of competencies.…”