Prevalence of pelvic examinations on anesthetized patients without informed consent

Survey design

The voluntary anonymous survey (Supplementary material) was administered on Google Forms. The survey was distributed to all osteopathic medical schools in the United States. Anyone who did not meet the inclusion criteria or sign the informed consent was excluded from the study. The survey began with the informed consent form and followed by questions regarding general demographic information, their involvement in performing pelvic examinations on anesthetized patients while on OB-GYN rotations, their understanding and perception of performing pelvic examinations on patients under anesthesia without their explicit consent, and possible reasons for this common practice. The survey also inquired whether there were any medical students who refused to perform pelvic examinations on anesthetized patients despite being asked by their preceptors and whether they experienced any repercussions of this refusal. The survey took approximately 5 minutes to complete and comprised of questions utilizing multiple choice, checkboxes, and free text. Responses were collected over five months from May to September 2023. The email addresses linked to the survey responses were removed, and the entire data set was de-identified by an independent analyst.

Statistical analysis

According to the AOA’s 2020–2021 Osteopathic Medical Professional Report, there are approximately 33,800 medical students registered as osteopathic medical students in the country [15]. The Student Osteopathic Medical Association (SOMA) data analysis indicates that 15,000 of those students are part of the SOMA, with roughly 3,000 students receiving weekly SOMA emails. The participants were recruited through SOMA’s internal chapter email lists, outreach emails, and SOMA’s social media accounts. Therefore, the survey sample size was determined to be 380 utilizing a 95 % confidence interval by utilizing the Qualtrics Sample Size Calculator [16]. The general data analysis was performed through basic Microsoft Excel functions. The corresponding survey responses, frequencies, and percentages were reported.

Demographics

The survey collected 310 responses. However, 19 of them were excluded because they indicated that they had not completed their OB-GYN rotation at the time of study participation, bringing the total number of eligible participants to 291. The participants self-reported their race and gender, as shown in Table 1. Notably, 68.4 % (199) were females, 28.9 % (84) were males, 1.72 % (5) preferred not to say, and 1.03 % (3) identified themselves as nonbinary.

Medical students’ perception of performing pelvic examinations under anesthesia

When participants were asked if the practice of performing pelvic examinations on anesthetized patients is considered ethical, 94.2 % (274) indicated “No” with 83.5 % (243) considering the practice akin to sexual assault. Among the participants, 99.9 % (290) expressed the correct understanding of what constitutes informed consent, stating that written or verbal consent must be provided for students to perform the pelvic examinations on anesthetized patients even if consents were given separately to their attending preceptors. When asked if the students ever performed a pelvic examination on anesthetized patients while on their OB-GYN clerkship rotations, 40.9 % (119) indicated “Yes.” However, among those who performed pelvic examinations on patients under anesthesia, only 26.0 % (31) had obtained explicit consent from the patients prior to anesthesia, whereas 57.1 % (68) participants had not. The remaining 16.9 % (20) of respondents did not answer the survey question on whether explicit consent had been obtained. Notably, the number of pelvic examinations performed on anesthetized patients ranged widely from 1 to 25 with a median number of 10. Moreover, when asked if the students had been educated to obtain explicit consent for them to perform a pelvic examination on anesthetized patients, 37.8 % (45) responded “Yes” whereas 58.9 % (70) said they had not been given the proper education to obtain consents by the preceptors or rotation administration, and 3.36 % (4) preferred not to answer this question. The summary of incidences of medical students performing pelvic examinations on anesthetized patients with or without consent is illustrated below in Table 2.

Possible reasons for medical students performing pelvic examinations on anesthetized patients

When asked what the participants thought were the possible reasons for practicing pelvic examinations on anesthetized patients, most cited efficiency of practice, lack of personal education, and policy awareness (79 %, 235) as well as being in unique positions as medical students whose clerkship grades are often determined by their willingness to do what is asked of them by their preceptors. Many participants 93.1 % (271) indicated that they did not know whether their state has a policy requiring explicit consent for performing pelvic examinations on unconscious patients. When asked if they ever refused to perform pelvic examinations on anesthetized patients, understanding that this act was considered unethical, only 5.1 % (15) refused, whereas 33.7 % (98) felt that they could not refuse when they were asked by their preceptors. Most of the participants (61.2 %, 178) preferred not to answer this question. Out of the 15 participants who refused to perform the pelvic examination without explicit consent, 66.7 % (10) of students indicated that they were scrutinized later by their preceptors for refusing to perform the pelvic examination. Table 3 summarizes the number of medical students who refused to perform the pelvic examinations on anesthetized patients when asked by their preceptors. Some further elaborated that their refusal was viewed as insubordinate and a refusal to learn. When asked if there should be a separate signature line on the patients’ consent forms for any surgical procedures involving performing pelvic examinations under anesthesia by medical students, 79 % (230) indicated “Yes.”

Medical students’ perception of performing pelvic examinations under anesthesia

Informed consent is a vital part of medical education on clinical rotations. Our study found that there is a deficiency in medical students’ understanding of needing to obtain consent for pelvic examinations under anesthesia. In addition, different hospitals may have varying administrative policies and instructions surrounding informed consent. They may also contain unclear language regarding informed consent procedures, posing a challenge to medical students’ understanding of when pelvic examinations under anesthesia should be performed.

Incidences of performing pelvic examinations on anesthetized patients by medical students

It has been consistently mentioned in professional society statements and state laws that pelvic examinations should not be performed if they are not related to the planned procedure [1], 14]. Although the general population views pelvic examinations under anesthesia without consent as unethical, medical students may still participate in them because they fear punitive actions if they decline due to their subordinate position, even when knowing that pelvic examinations under anesthesia are unethical. The 16.9 % (20) of medical students who preferred to not answer whether consent was obtained or not prior to performing pelvic examinations under anesthesia raises concern for the moral crisis experienced by students in these situations. Furthermore, most students in this study reported that they were not properly educated to obtain consent prior to performing pelvic examinations on anesthetized patients. This poses the question of whether the responsibility for educating students on obtaining explicit consent for procedures lies on the precepting physician, preclinical, or clinical education.

Possible reasons for medical students performing pelvic examinations on anesthetized patients

The occurrence of pelvic examinations under anesthesia has multiple potential sources including efficiency of practice, lack of policy awareness, and the hierarchical culture of medicine. Those involved in medical education may find instructing medical students to perform pelvic examinations under anesthesia before the commencement of a procedure in the operating room to be the most time-efficient and practical way of allowing medical students to practice this physical examination skill under their supervision. This may be exacerbated by instructors with busy schedules or those at institutions with a higher volume and complexity of patients. Contributing to medical students’ experiences with pelvic examinations under anesthesia is a lack of understanding of institutional policies and variance in these policies between institutions. Students may be unable to cite a policy or provide their superiors with reasoning, posing a barrier to students’ refusal to conduct pelvic examinations. Finally, the long-standing hierarchical nature of medicine and the historical pattern of subordination to superiors in medical training creates a challenging environment for students to voice their concerns.

Ways to address the issue

The practice of performing pelvic examinations under anesthesia without consent may be addressed through changes in the approach to teaching pelvic examinations. Medical student education may be amended to emphasize the importance of informed consent and patient autonomy. On the institutional side, we recommend that hospitals and institutions proactively disclose their consent policies to medical students before clerkships, ensuring student awareness and understanding of protocols. Furthermore, ultrasound simulation training could be conducted with the mannequin models to educate students on pelvic anatomy and pathology [17]. In recent years, the utilization of immersive technologies (e.g., virtual reality [VR]) in medical education has grown due to its effectiveness in teaching both procedural and interpersonal skills [18]. VR technology also exists for practicing pelvic examinations [19]. Medical students have reported VR to be helpful in learning to perform a pelvic examination, suggesting that VR may be another teaching modality for learning these sensitive examinations [20].

There are many different teaching modalities for acquiring pelvic examination skills. However, the hierarchical culture of medical training presents a systemic challenge that may require more than diverse teaching modalities to overcome [21]. This culture often places pressure on medical students, contributing to fear and intimidation. A starting point to tackle these issues may be eliminating any negative consequences for students who refuse to perform pelvic examinations under anesthesia without informed consent. Additionally, open communication may be achieved through regular feedback sessions with the supervising instructor, and this practice may be effective in addressing intimidation or fear felt by students. Furthermore, creating a supportive environment where students can anonymously report concerns about insufficient consent obtained may further this goal. In alignment with osteopathic tenets and the practice of osteopathic medicine, these measures also contribute to learning professionalism and maintaining respect for patient privacy as a medical student.

Recommendations

As outlined by the guidelines of the US Department of Health and Human Services through the Centers for Medicaid and Medicare Services, consent must be obtained for any pelvic examination regardless of whether patients are anesthetized or not. Performing a pelvic examination without a patient’s informed consent is not allowed in osteopathic medicine. Currently, there are approximately 20 states with consent laws in place, and we expect that many more states will follow this practice and require consenting laws to be universal for any pelvic examination. We would recommend implementing institutional protocols to ensure the practice of obtaining consent from any patients before performing a pelvic examination. Additionally, resident physicians and attending physicians on the team should pay extra attention to ensure that the patients are consented if any medical students are present on their rotating services.

Study limitations

This study’s limitations include the inclusion of only osteopathic medical students’ experiences, and the hesitation of medical students to honestly report occurrences of and attitudes toward the practice of pelvic examinations under anesthesia with unclear status of informed consent. The findings here are also limited by an insufficient sample size. They may also be affected by the profound lack of existing literature on this topic and selection bias, namely volunteer and/or nonresponse bias.

Future work

Further studies are necessary to elucidate this topic in medical education. Larger sample sizes and a more diverse student population are needed to improve the reliability and validity of our findings. Potential areas of further study include methods of preventing unconsented pelvic examinations from being performed under anesthesia and qualities of clear institutional policies regarding informed consent and their standardization. It is recognized that those under anesthesia are incapacitated to make their own medical decisions evidenced by the common practice of surgeons to discuss potential intraoperative complications and decisions before procedures [1]. Similarly, those under anesthesia cannot then consent to a pelvic examination conducted by a medical student if not informed beforehand. Efforts to elucidate medical student participation in pelvic examinations under anesthesia and obtaining informed consent may include supplemental consent forms that explicitly include medical students, attestation of discussion on consent forms, and including the term “exam under anesthesia” on consent forms as a standardized practice [1]. There are currently only 20 states in the country that passed a bill requiring obtaining consent for pelvic examinations under anesthesia [13]. Through this study, our hope is to raise awareness of this important issue and to encourage institutions to develop and implement policies regarding pelvic examinations under anesthesia.