Medical student Hilary Gerber of Mom’s Tinfoil Hat was offered the chance to perform a pelvic exam on an unconscious female patient by an operating room nurse at the local hospital not affiliated with her school. Wrote Gerber:
I participated in a dilation and curettage on a woman who was experiencing an incomplete abortion. I was in the room before the procedure and the OR nurse offered to let me do a pelvic exam on her, since the patient was already anesthetized.
Gerber declined the offer.
Although I was fascinated by the opportunity, and initially was tempted by the learning experience, I didn’t want to do it without her permission, and made myself consider her as a patient and a person, not as a pathology or anatomy in front of me. Yes, I knew she was going to have a pelvic procedure that she already consented to, and I even had the opportunity to introduce myself to her before she was anesthetized, but I knew it wasn’t diagnostic for me to do a pelvic on her in this situation, wouldn’t change the course of her treatment, and questioned the ethics of it.
She is not alone in her unwillingness to perform a pelvic exam on an anesthetized patient without her consent. Many students, such as those in the Devry Health Information Technology program, learn the ethics of healthcare throughout their years studying. Dr. Michael Greger, author of Heart Failure: Diary of a Third Year Medical Student, refused to perform nonconsensual pelvic exams on anesthetized patients as a student. This 2003 interview with Michael Greger is archived on the now inactive ShamExam.org website:
Are all women who are put under general anesthesia in a hospital practiced on by students while unconscious?
All women in the OB/GYN department at most teaching hospitals and hospitals affiliated with a medical school are. If you’re anesthetized and you’re in the OB/GYN department, you probably have had students practice pelvic exams on you regardless of what you’re in the hospital for - even if the procedure you need doesn’t require a pelvic exam!
Additionally, while doctors don’t go to other departments — such as general surgery patients, neurosurgery patients or cardiac surgery patients — if your surgeon is an OB/GYN, odds are there’s going to be a team of hungry medical students waiting for you to fall asleep.
When you say a team, how many people do you mean?
That depends. There’s the attending, a few residents, an intern and then as many medical students as they can round up.
However, I’m less concerned about interns and residents. They are doctors that have a role in that patient’s care, so doing a pelvic exam might be useful for them. But for medical students, no one even pretends it’s about the patient. Patients are strictly tools for our education. There’s no thought that there’s any benefit to the individual patient when medical students are just lining up in there.
When you were a medical student, did all your classmates perform non-consensual pelvic exams on women?
Yes, particularly the male students practiced pelvic exams on anesthetized women. As of last year, which was the last time I checked, they still do.
Why are male students more likely to perform non-consensual pelvic exams?
The medical community assumes that women will be less likely to allow male students practice on them if asked. So the male students are quicker to jump at the opportunity to practice on women who are unconscious.
Are there ways for student to learn how to perform pelvic exams other than on non-consenting women?
Yes, there’s a surrogate program that pays volunteers. If you contact a chairperson at an OB/GYN department or medical school they will tell you all about the surrogate program if they have one. What they won’t tell you is that in addition to the surrogate program they still carry out this practice. At [omitted], second year students practiced on a surrogate. That’s how I learned how to do it. But then in my third year on my OB/GYN rotation I performed pelvic exams on unconscious patients. Women would come in for appendicitis or something. Then, once they’re asleep, the crowd gathers, line forms to the left.
If teaching hospitals and medical schools have surrogates offering to consent to pelvic exams, why perform non-consensual ones?
Money. It’s expensive. And takes time while waiting for someone to volunteer. At least that’s what medical schools will say.
Can you explain what happens during these non-consensual pelvic exams?
They are usually “bi-digital” exams. This means students insert two fingers as deeply as they can into the vagina with one hand and use the other hand to feel around the outside of the abdomen for the ovaries. What they’re trying to do is trap the ovaries between their two fingers and their hand and feel for the internal organs from the inside. Sometimes, speculums are also used in the exams.
And what does this teach the student?
Very little in terms of how to do a proper pelvic exam. The art of doing a pelvic exam is how to do it while making the woman feel comfortable. When a patient is unconscious, obviously she can’t tell you what’s uncomfortable, what you’re doing right or wrong, what hurts. And, it feels completely different because the musculature is completely relaxed because of the anesthesia. So it doesn’t feel the same when you do a pelvic exam on a woman who is awake.
So why do the pelvic exams on unconscious women?
Because the student thinks, “Well, the more exams I do, the more spinal taps I do, the better I’ll be at it.” And then he thinks, “Hey, if I have to ask permission, I may not be able to do as many, so I may not be as good at it.” But that’s not really the case.
I often tell this story to illustrate my point:
In my physical diagnosis class at [omitted], students learned how to do rectal exams from a proctologist. I was waiting for my turn to perform a rectal exam.
When I was finally called in, I was shocked to find a poor guy bent over a table with his pants around his ankles. I’d never met the patient or the doctor before and I wondered how the doctor was going to explain to the patient why he was going to get a second exam.
Then the doctor told the patient, “I want to get a second opinion by a specialist.” All of a sudden though I was just a 2nd year medical student, I was not only a doctor but a specialist! I went in there sticking my finger out with no idea what I was doing. Obviously, the proctologist couldn’t tell me anything, either, because I was now the specialist. So, the educational experience for me was absolutely useless.
When you go in as a medical student to do your first procedures like a blood draw, or putting in your first IV, if you’re introduced by the resident as “doctor” — which almost everyone is — and they pretend they know what they’re doing, all the resident can do is stand behind the patient and surreptitiously tug at their ear and make sign language that what you’re doing is wrong.
However, if you respect the patient as a human being and go in there and say. “My name is Michael Greger, I’m a medical student. I’ve never done this procedure before but there’s someone right here that’s going to take me step-by-step through the procedure. Would you mind if I did this?” and actually sit down with them and establish a relationship and rapport, medical students will be surprised at how many people are willing to let us do all sorts of things to themselves and their families. Then the doctor can take you step-by-step because you’re not pretending you’re someone you’re not.
Of course, doctors know they won’t have this problem when the patient is anesthetized, because then you can go step-by-step and you don’t have to respect anything.
What stops students from simply asking the patient for permission?
When I was a student and approached the chairperson of my department and said I was uncomfortable with this, and he said, “I don’t see anything wrong with it.” My response was, “If there’s nothing wrong it, then you won’t mind if I ask permission.” He said I couldn’t do that. He knew that women would be absolutely outraged at the thought, and so, no one would tell them anything.
As a woman, if I just had surgery at a teaching hospital and asked my doctor if students had been practicing pelvic exams on me without my consent while I was unconscious, what would he say?
Particularly in this perceived climate of liability, doctors wouldn’t say anything. Medical ethics literature reveals surveys that say 50% of doctors blatantly falsify patient records and 70% mistreat patients. I had a case in my internship where doctors literally lied about killing a patient. They have so little respect for the autonomy of the patient, or that patients have any say in what they do or how they carry out their practice. Doctors know the right thing to do, but they’ve been socialized to fit in with the team and protect their own.
So, how can a woman prevent non-consensual pelvic exams happening to her?
All you can do is ask and hope that your doctor will honor your request. Once you’re asleep, however, you have no power. And what a powerless thing for women to know this goes on and think, “Well, I’m just going to have to trust my doctor.”
What if you don’t trust your doctor?
Women can write on their bikini line, “I do not give consent for medical students to practice pelvic exams on me” in marker. Then as soon as the clothes come off or the robe is lifted and all the medical students are getting on their latex gloves they can see that message. And that will stop them.
I was inspired to think up this tip because of patient advocates like Bernie Siegel, M.D., who recommend that patients use a magic marker to write “Wrong leg” or “Wrong arm” on their healthy body parts to prevent them their doctor from performing surgery on the wrong limb - a common mistake.
Has any medical governing body, like the American Medical Association, ever commented on non-consensual pelvic exams?
Over and over medical authorities say this practice is egregious. In numerous medical ethics articles this practice is described as an outrageous assault on the dignity and autonomy of the patient.
One quote from these articles reads: “This practice shows a lack of respect to the patient as a person, renewing a moral insensitivity and misuse of power. It is just one of the ways in which physicians abuse their power and have shown themselves unwilling to police themselves in matters of ethics, especially in regards to female patients.”
Since medical authorities are against non-consensual pelvic exams, have they ever tried to ban them?
They talk the talk, but when it comes to changing the culture of medicine, nothing happens. But then there’s that paradox that can be exploited. You can say, “Your own medical ethicists say this is wrong. So how can you continue to do it?”
Do you believe there should be federal legislation banning non-consensual pelvic exams?
Yes, you shouldn’t have to just trust that your doctor isn’t lying to you when he says students didn’t practice pelvic exams on you while under anesthesia. This practice should be outlawed. There should be professional guidelines. There should be federal guidelines.
This practice is already illegal in Massachusetts — although, it still happens there all the time. But it’s all about public knowledge. I believe that’s the primary role of proposing legislation, because articles in the media about the legislation would help spark a national debate and inform the public. And, the most effective thing is public knowledge.
If more people know about this and are outraged, then medical students will be more likely to go to the head of their department and say, “I don’t comfortable doing this.” And if the response to their protest is, “There’s nothing wrong with this,” the students can throw a stack of articles on the desk and say, “What do you mean? People are outraged all over the world!”
Is this practice worldwide?
Yes, and wherever this has come out, public outrage has followed. For instance, in New Zealand, there was outrage across the whole country when this practice was discovered. And that led it to stop.
How do medical students feel about performing non-consensual pelvic exams?
When I talk about non-consensual pelvic exams during my lectures, the majority of first and second year medical students - both male and female - are just horrified to hear that this goes on. They say, “This will never happen in our school!” But then there’s usually a third or fourth year student who attends the lecture and raises his hand and says, “I did this just last week. Yes, this goes on here.”
How do the attending physicians who require the students to perform non-consensual exams feel about the practice?
The attending physicians are almost without exception supportive of the practice, haven’t even thought about it, or don’t consider anything wrong with it. I’ve seen female just as likely as male attendings support the practice.
In fact, the only people who are fine with not asking permission are doctors. They’re so out of touch with the world and society. This is where they’re weakest.
Why do attending physicians feel this way?
I’ve been told that they don’t see anything wrong with it. They don’t see anything unethical about it at all. They think, “Huh, we just never thought anyone would mind.” In fact, a quote in a recent article in the response written in response to the American Journal of OB/GYN article this month [March 2003] quoted the residency director of Johns Hopkins as saying “I don’t think any of us even think about it. It’s just so standard as to how you train medical students.”
If the majority of first and second year med students are horrified by the practice, then how do they transform into third and fourth-year students who perform the non-consensual pelvic exams? And then into future attending doctors who require other students to perform them?
Good question. Well, one interesting statistic that you don’t hear discussed is that people talk about the ¼ of med students who say it’s “unimportant” to ask consent. And that’s outrageous, obviously. But if you analyze this data, those were students who had completed or who were in the middle of their OB/GYN rotation.
If you ask students before they get to that point, before they do their rotation, before they’re forced into a position where they have to do this kind of thing, the number is significantly lower - 17%.
So what happens to medical students when they’re placed in this situation that they undergo this shift, this eroding of their ethical principal?
In my book, I talk about some of the studies that show, if anything, moral reasoning may be inhibited by medical education, that ethical sensitivity increases during the first and second years of medical school but then decreases throughout the rest of medical school. So 4th year medical students who graduate and get their M.D. are less medically sensitive than when they entered into med school!
Why do you think there’s such a dramatic shift from 1st and 2nd year med students who don’t want to perform non-consensual to 3rd and 4th year students who feel it’s okay?
Medical school has a cult-like atmosphere. You’re all immersed in this one lifestyle, you’re sleep deprived, you’re not eating enough, you’re all dressed the same. So, when you’re presented with something of questionable morality, you have no time to introspect or self-reflect or think about it. You don’t have time to question whether things are right or wrong. Without any kind of outside contact, you just get caught up in it. You go along with the team and go with the culture of medicine.
How can students who oppose this practice convince their schools to ban it?
They need to organize. To get together as a group and approach the chair of their department and say, “We as a group feel uncomfortable with this.” I don’t want anyone to be put in the position I was, this lone person who sticks their neck out and then gets dismissed or worse. But if they stand together as a group, they can come together and say, “We as a class…” or “We five people on this rotation feel uncomfortable with this.” My hope is that medical schools then just can’t ignore it.
Gerber blogged that she hopes to maintain the “ethical sensitivity” mentioned by Greger into her future career in OB-GYN.
I hope that if I do get my career in ob/gyn, I do continue to consider my patients as patients. I know there is a crisis in ob/gyn in which obstetrics is turning more into a game of avoiding liability and “moving meat”, and I hope my switch won’t get flipped to the point where my nameless, faceless patient is just a medicolegal liability or a long labor to be avoided by an unnecessary surgery.