http://www.charlotte.com/mld/observer/living/health/5467501.htm
N.C. schools: Pelvic exams not gratuitous
KAREN GARLOCH
Some women expressed disgust over recent news reports about the little-known practice of medical students performing pelvic exams on women, without their consent, while they're under anesthesia.
The discussion started with a February article in the American Journal of Obstetrics and Gynecology that reported on student views about the practice at five medical schools in Philadelphia.
The article's authors included a former University of Pennsylvania medical student who had objected to doing the exams without getting consent from patients.
Some readers came away believing that multiple students perform pelvic exams, solely for practice, on women anesthetized for surgery of any kind. They were bothered by the potential for abuse.
After talking with doctors at North Carolina's four medical schools, I'm more comfortable the practice isn't done gratuitously by students honing their beginners' skills on unsuspecting, unconscious females in the operating room.
Medical school faculty at Duke University, UNC Chapel Hill, Wake Forest University and East Carolina University said students do perform pelvic exams, but they aren't done on anesthetized women undergoing just any surgery, only gynecological surgery.
Doctors emphasized such exams are always done under anesthesia before gynecological surgery; they aren't simply added to give students experience. Also, they said, pelvic exams aren't done by multiple students, only the one -- or sometimes two -- on an ob/gyn patient's care team.
"We have never endorsed a patient being asleep and just multiple people doing pelvic exams," said Dr. Wesley Fowler, director of gynecologic surgery at UNC Chapel Hill. "Students do do pelvic exams under anesthesia because that is their patient, and it is related to that patient's care."
Dr. Alison Weidner, chief of the division of gynecology at Duke, said students perform exams only if they're part of a patient's care team.
"I don't think it's a common practice or even considered acceptable to gratuitously bring in other (students) who aren't integrally involved in the patients' care," she said. "That just doesn't occur."
Relief from pain
Weidner and others said it is important to get pelvic exams while patients are anesthetized, to make sure findings match those of exams done when patients were awake."The pelvic exam is very different in the unanesthetized person than it is in somebody who's anesthetized and pain-free," said Dr. Edward Newton, chairman of ob/gyn at ECU.
"Somebody with an ectopic pregnancy, it's sore and hurts. They tighten up and you don't get as good an exam. When they have complete relief of their pain, you can really feel what's going on there. There are times, actually frequently, that the surgery may actually be changed on the basis of the exam (under anesthesia)."
In teaching hospitals, a patient's care team includes med students and residents. Patients often will have met each team member, but not always.
Like other doctors, Weidner said she talks with patients, before surgery, about the need to do an exam under anesthesia, but she doesn't get specific written consent for a medical student to perform it.
Because Duke is a teaching hospital, she said, "patients who come to see me understand that ... in many cases medical students are going to be part of their care team."
Fowler said he doesn't ask a patient specifically to allow a medical student to perform a pelvic exam, just as he doesn't get consent every time someone draws blood.
"That's part of your care," he said. "When all else fails, use a little bit of common sense. That's what we try to do. Respect the patients."
Privacy and dignity
Dr. Joseph Ernest, acting chairman of ob/gyn at Wake Forest, said pelvic exams under anesthesia played a larger role in diagnosis before the advent of accurate imaging techniques, such as ultrasound and CT scans.
Today, he said, students learn gynecological exams primarily by working in school-affiliated clinics or by working with paid volunteers. All four N.C. med schools pay volunteers to allow students to perform pelvic exams while they're awake.
What bothered Newton about the recent publicity was that it suggested doctors were physically abusing patients.
"When they go to the operating room, I'm a real stickler. All the windows are covered. We face the operating table away from the door. There is always a woman in the room.
"I think there's a cultural sensitivity to these things, especially in ob/gyn," he said. "You need to protect privacy and dignity. We try to do that."
One female doctor in Charlotte, who asked not to be named, said she never thought of the exams, even without specific consent, as harmful.
She suggested patients have "much more important things to worry about in medical care," including whether they are getting correctly diagnosed or whether their doctors and nurses are communicating with each other.