Pelvic exams at Medial School scrutinized

A growing national controversy over how much patients should be informed of procedures performed on them while they are under anesthesia has put teaching hospitals - including those affiliated with Tufts - in an uncomfortable limelight.

The procedure in question is pelvic exams conducted on anesthetized women by medical students without the women's explicit consent, something that a Tufts Medical School alumnus is accusing the school of doing.

Tufts Medical School administrators claim that exams done solely for the students' benefit do not occur at Tufts, although Dr. Michael Greger (M '98) has claimed otherwise - both in a book criticizing medical education and in public lectures across the country.

Medical students receive their first experience performing a pelvic exam, which involves inserting two fingers into the vagina in order to locate and examine the ovaries, as second year students. This first examination is conducted on a conscious woman contracted for this specific purpose. However, as third-year students, during a required obstetrics/gynecology (OB/GYN) clerkship, students conduct pelvic exams on patients who will undergo surgery.

Tufts said that its policy is very clear. "The only time that patients are examined under anesthesia is when it's relevant to the medical procedure," said Dr. Robert Kennison, a professor of OB/GYN at the medical school. "The exam is always important for the performance of the medical procedure."

There is some debate over the circumstances under which examinations are done in medical schools; some allege that the women are used to provide students with experience and that the exams are not necessary for the surgery, while others claim that only students who will be assisting in the surgery perform these necessary examinations.

Greger's claims contradict the Med School's, at least with regards to the procedure five years ago when he was a student. In his book, Heart Attack: Diary of a Third Year Medical Student he states, "at Tufts, medical students - particularly male students - practice pelvic exams on anesthetized women without their consent and without their knowledge. Women come in for surgery and, once they're asleep, we all gather around; line forms to the left."

The Tufts administration categorically denies that this sort of practice, to their knowledge, ever took place. Students contacted either did not respond or would not speak on the record.

One student said that to the best of her knowledge the only students conducting pelvic exams on anesthetized women were those who would be participating in the surgical procedure, and when it is necessary to the surgery.

Administrators feel that the issue is more about a communication failure between teachers and students. "I think one of the reasons this [confusion] has happened is that students aren't there at the consent time," Kennison said. "There's a perception that there has not been consent."

Kennison also said that part of the misunderstanding is due to a potential lack of clarity in the consent procedure. Although consent must be obtained before any procedure, it is not clear whether women understand what exactly they are consenting to when they agree to be operated upon.

"All patients who come here are made aware that they are coming to a teaching institution," Kennison said. Although the surgical consent forms vary, all cover "who is going to be doing the surgery and participating in it." Student assistance is explicit, and Kennison said that their participation, as necessary for that assistance, is implicit in the consent.

Although patients can request that students not participate in their surgery, Kennison admitted that this option is not necessarily made clear to the patients. However, "there is this discussion at really high levels, as to what policy has been specifically stated," he said. In response to the recent controversy, the American College of Obstetrics and Gynecology, an umbrella organization for all professional OB/GYN practitioners, will release a statement from their ethics committee on examinations conducted by people in training, Kennison said.

In other teaching hospitals it is questionable to what extent students are performing exams for educational purposes, though doctors are emphatic as to the teaching utility of exams done on anesthetized women. The muscles are more relaxed, allowing the students to feel the organs without interference, and the patient cannot feel the sometimes painful mistakes of a novice examiner.

Greger, however, argues that "the art of doing a pelvic exam has very little to do with the technical skill, it's all about making the woman feel comfortable... When somebody is asleep... as an educational experience it's really quite limited."

The debate was sparked by a February article in the American Journal of Obstetrics and Gynecology, detailing the change in the mindset of medical students from first and second year - where many claim that they would feel uncomfortable perfoming pelvic exams on anesthetized women who had not consented to them - to third and fourth year students who did not express the same reservations.

In addition, in early March, several teaching hospitals attached to prestigious schools, including Harvard, announced that they would be changing their procedure to ensure that only students participating in surgical procedures would perform pelvic exams on anesthetized women.

News stories caught the attention of many, and spurred the creation of People Against Non-Consensual Pelvic Exam (Non-Con). Gabrielle Lichterman, founder and executive director of the group, claims that over 400 teaching hospitals in the country practice non-consensual exams on women, and is trying to lobby senators to pass federal legislation to control the practice.