Consent Policies for Pelvic Exams Under Anesthesia Performed by Medical Students: A National Assessment

Abstract

Background:

Medical students report low confidence in their ability to perform pelvic exams. Pelvic exams under anesthesia (EUA) are one way for students to practice the exam, but this needs to be balanced with patients' bodily autonomy through explicit disclosure and consent. This study seeks to characterize U.S. medical schools' policies regarding the consent process for students to perform pelvic EUA.

Materials and Methods:

Obstetrics and gynecology clerkship directors were anonymously surveyed about their medical school affiliated hospitals' (MSAH) consent policies for pelvic EUA in general and explicitly for medical students. Chi-square and Fisher's exact test were used to test for differences between categorical variables and thematic analysis was used to review qualitative responses.

Results:

A total of 87 clerkship directors completed the survey (44.4% response rate). Most MSAH explicitly consent patients for pelvic EUA (80.2%), and specifically for performance by medical students (79.1%). Sixty-nine respondents (79.3%) stated that performing pelvic EUA is important for medical student education. Five themes were identified from review of qualitative responses, including consent policy details, the importance of pelvic EUA, other opportunities for pelvic exam teaching, barriers to standardization, and outside guidance.

Conclusions:

The pelvic EUA is a necessary part of both surgical care and medical education but patient dignity must be protected too. Most MSAH have consent policies for students to perform pelvic EUA. Still, these policies need to be further strengthened and standardized across institutions to protect patients' rights while continuing to teach students the pelvic exam.

Introduction

Many recent, often shocking, lay-press news articles report on pelvic exams under anesthesia (EUA), decrying incomplete policies surrounding informed consent and improper execution of these policies.^1
–3 Earlier scholarly work considers the legal, moral, and ethical groundwork for improved pelvic EUA consent processes.^4

–9 The necessity of informed consent is justified by the tenets of patient autonomy and rights.⁶ Because of the sensitive nature of the pelvic exam, informed consent before pelvic EUA becomes even more important to protect patients' rights and foster trust between patient and clinician. Although recent work has brought consent for pelvic EUA to the forefront, consent for pelvic EUA within the scope of medical education has been less thoroughly examined.¹⁰

Performing a pelvic exam is an essential part of providing comprehensive women's health care.¹¹ However, medical students and recent graduates report they do not feel comfortable performing pelvic exams.¹² Given the sensitive nature of the exam, trainee education in EUA during operative procedures helps eliminate worry over patient comfortability while learning the exam, improving student confidence and ability.^13,14 This ultimately impacts the patient experience and likelihood to get a required pelvic exam in the future.^15,16 In its most recent guidelines, the Association of Professors of Gynecology and Obstetrics (APGO) asserts that medical students going into any specialty should perform pelvic exams, including EUA, throughout their training. The statement clarifies, however, that students should only perform pelvic EUA if it is “explicitly consented to, related to the planned procedure, performed by a student who is recognized by the patient as a part of their care team, and done under direct supervision by the educator.”¹⁷

Medical students need to learn the pelvic exam to care for their future patients. Previous work has shown that students desire explicit informed consent for educational pelvic EUA in the operating room.¹⁸ However, another study found that medical students believe current policies are inadequate and leave room for unethical practice.¹⁹ Through this national survey of OB/GYN clerkship directors, we aim to describe U.S. medical school consent policies for students performing pelvic EUA to understand the current policies and uncover areas for improvement.

Materials and Methods

Survey design and distribution

Participants were U.S. OB/GYN clerkship directors recruited over e-mail using the APGO national OB/GYN clerkship director listserv in the Fall of 2022. The APGO clerkship director e-mail listserv is updated annually and providing e-mails to the listserv is voluntary. Three e-mail reminders were sent after the initial recruitment e-mail. No incentives were given. This study was considered exempt from the Institutional Review Board.

The 20-item survey assessed clerkship director and medical school demographics, consent policies for pelvic EUA at respondents' hospitals in general and specifically for medical students, the importance of medical student involvement in pelvic EUA, and knowledge of legislation regarding pelvic EUA in their state (Supplementary Appendix Table SA1). Questions used multiple-choice answers on a 5-point Likert scale, and one open-text option dedicated to additional details surrounding the institutional pelvic EUA consent process and involvement of medical students. Previous literature investigating medical student's perceptions about performing pelvic EUAs guided the development of some survey items specific to medical student consent policies.¹⁸ The survey was pilot tested on seven undergraduate education leadership faculty who perform pelvic exams at our institution before administering the survey to the participants.

Statistical analysis

Survey data were recorded using Research Electronic Data Capture (REDCap), a secure web-based platform. The data were stored on encrypted Brigham and Women's Hospital servers. For analysis, data were exported from REDCap to Stata version 16.0. Descriptive statistics were reported as frequencies and proportions. A chi-square test was performed to test for differences between categorical variables. If the sample size in one group was <5, Fisher's exact test was used instead of a chi-square test. Thematic analysis was performed to review the qualitative, free-text responses. Two study team members (A.M.K, A.P.) independently reviewed the responses, met to discuss common themes, then finalized and defined the identified themes.

Results

We received responses from 87 of the 196 (44.4%) surveyed U.S. OB/GYN clerkships. All four regions of the country were represented: 15 (7.2%) respondents from the Midwest, 27 (31.0%) from the Northeast, 27 (31.0%) from the South, and 18 (20.7%) from the West. Medical school sizes varied, with most (80.4%) having >100 students. Most respondents, 77 (89.5%), were clerkship directors, whereas 4 (4.7%) respondents were associate clerkship directors and 5 (5.8%) respondents indicated they had another role in the clerkship. Eight respondents (9.2%) had been in the role for less than a year, 41 (56.3%) for 1–5 years, and 38 (43.7%) for >5 years. This demographic data are summarized in Table 1.

Table 1.

Demographics of Respondents' Affiliated Medical Schools and OB/GYN Clerkship Roles (n = 87)

	n	%
Medical school region
Midwest	15	17.2
Northeast	27	31.0
South	27	31.0
West	18	20.7
Medical school size
≤50	1	1.2
50–100	16	18.4
101–150	27	31.0
151–200	28	32.3
201 +	15	17.2
Clerkship role
Clerkship Director	77	89.5
Associate Clerkship Director	4	4.7
Other	5	5.8
Length in role
≤1 year	8	9.2
1–5 years	41	56.3
5 + years	38	43.7

All but one respondent indicated that their medical school affiliated hospitals (MSAH) perform pelvic EUA (98.9%). Most MSAHs explicitly consent patients for pelvic EUA (69, 80.2%). The only statistically significant association was between program regional location and an explicit consent policy for pelvic EUA (p = 0.038), with only two programs in the South and one program in the West without an explicit consent policy for pelvic EUA. Of the MSAHs that do explicitly consent patients for pelvic EUA, 59 (86.8%) have written consents, and 9 (13.2%) verbally consent patients.

Most MSAHs also explicitly consent patients for medical students performing pelvic EUA (68, 79.1%). There was more variability with written versus verbal consent, with 48 (71.6%) consenting patients in writing and 19 (28.4%) consenting patients verbally. Twenty (25.6%) respondents indicated that their policy for consenting patients for medical students performing pelvic EUA had been revised in the past year, and 7 (9.0%) indicated that the policy is currently under review. Thirty-six (41.4%) respondents were aware of legislation requiring explicit consent for pelvic EUA in their state, similar to the percentage of states with legislation prohibiting unconsented pelvic EUA (21 states, 42.0%).

Seventy-one (91.0%) respondents reported medical students are informed of the pelvic EUA policies during their clerkship and 81 (95.3%) said that medical students are also informed of their specific role during pelvic EUA. All respondents indicated that medical students have opportunities to perform pelvic exams outside of pelvic EUA. Yet, 54 (62.1%) respondents believed that performing pelvic EUA was very important for medical students, and another 15 (17.2%) thought it was somewhat important.

Five themes were identified within the free-text responses to the open-ended question regarding MSAH's pelvic EUA consent process and the involvement of medical students. The themes include consent policy details around medical students performing pelvic EUA, the importance of pelvic EUA, other opportunities for pelvic exam teaching, the informality of policies and barriers to standardization, and outside guidance and legislation. Table 2 provides representative quotes from respondents for each of the themes.

Table 2.

Representative Quotes for Five Themes Identified from Write-in Responses

Theme	Quotes
Consent policy details around students performing pelvic EUA	“Students are required to meet the patient ahead of surgery if participating in their care. If there are other learners in the room but they aren't participating in the case but just observing, then they do not participate in the examination. Students can opt out of an exam under anesthesia as well.” “One consent is obtained which includes exam under anesthesia by any person of the surgical team as identified by the patient. The one student who is assigned to that patient—if they have helped with preop and care of the patient/and patient considers them a part of the care team—may perform a pelvic exam under anesthesia.” “We also emphasize that the attending takes the lead on obtaining consent for learner participation without the learner present, so as to help decrease the likelihood that the patient feels pressured into letting the learner participate if asked when the learner is in the room.”
Importance of pelvic EUA	“For students going into FM and IM who plan on doing pelvic exams, there will be less opportunity for them to learn this skill as they will not go through an OB/GYN residency.” “If students do not learn proper pelvic examination, the long-term effect is detriment to our patients.”
Other opportunities for pelvic exam teaching	“The second-year students have live pelvic models for their exams (female and male).” “Our students get >25 pelvic exams in the outpatient clinic on the OB/GYN clerkship and more on some family medicine clerkships.”
Informal policy/barriers to standardization	“No consistency across services or individual providers. No guidance from school or hospital. Generally accepted that a pelvic EUA is implied.” “The site I am at directly has a good policy that protects students and our patients. The other sites have no standardized process. We are working on standardizing across the board.”
Outside guidance/legislation	“We adhere to the guidelines set forth by APGO.” “In Florida, it is the law.”

APGO, Association of Professors of Gynecology and Obstetrics; EUA, exam under anesthesia; FM, Family Medicine; IM, Internal Medicine.

Discussion

The pelvic EUA is a necessary part of both surgical care and education but must be executed in a trauma-informed manner to protect patient bodily autonomy and the integrity of the medical profession. One key aspect to this is ensuring that patients are aware that a pelvic EUA will occur before their operation and who all of the participants are—including medical students. Explicit consent policies are crucial to ensure patients' rights are protected.

In our study, nearly all respondents reported that pelvic EUAs are performed at their MSAH, and the majority reported that patients are, in general, explicitly consented for pelvic EUAs. The majority of respondents also reported that there is an explicit consent policy for medical students performing pelvic EUA. Most MSAHs had not changed their policy in the past year (71.8%), even with recent legislature prohibiting unconsented pelvic EUA. At present, 21 states have made performing a pelvic EUA without explicit consent illegal, with 7 of these states passing this legislation in the past 2 years. Despite all respondents reporting that medical students have other opportunities to perform pelvic exams, a majority felt that pelvic EUAs were either very important or somewhat important for medical student education (79.3%).

We found a statistically significant correlation between respondent region and explicit consent policies for pelvic EUA in general (p = 0.038), although this did not bare out between region and explicit consent policies for medical student performance of pelvic EUAs. About 92.3% of respondents from the South and 94.1% of respondents from the West reported that their MSAH had an explicit policy regarding pelvic EUA consent, whereas only 80.0% of the Northeast and 60.0% of the Midwest had policies. No other statistically significant correlations were found between medical school size, awareness of legislation, clerkship director role, or length of time in role and explicit consent policies for pelvic EUAs in general or for medical students. There was no difference in response rate between the different regions, after accounting for the number of medical schools in each region.

That the majority of respondents report the existence of an explicit policy for medical students performing pelvic EUA is in keeping with recent demands for greater patient autonomy as reported in the lay media. These demands have been answered with the passage of recent laws; 21 (42.0%) states have legislation prohibiting unconsented pelvic EUA and 7 more states have bills under consideration now. Thirty-six (41.4%) respondents stated they were aware of legislation requiring consent for pelvic EUA. Still, only a few respondents mentioned state laws in the write-in section when discussing their consent policies. In addition, the correlation between presence of an explicit policy for consent for pelvic EUA in general and region of the MSAH did not align with legislation.

The South has the lowest proportion of states with legislation banning unauthorized pelvic EUA; however, it had a higher proportion of respondents indicating the presence of an explicit consent policy for pelvic EUA than the Northeast and Midwest and was on par with the West, which has the highest percentage of states with legislation. Potential reasons for this difference could be focus on individual rights in the Southern states or an assumption in the Northeast and Midwest regions that the pelvic EUA is “implied” and does not need explicit consent, as some respondents described in the open-text section.

An article published in 2021 found that 75% of medical students surveyed at one institution indicated a need for an explicit policy surrounding patient consent for their performance of pelvic EUA, in addition to reporting confusion surrounding their own institution's policy.¹⁸ Ninety-one percent of our respondents reported that they inform medical students of policies for pelvic EUAs, pointing to a disconnect between clerkship directors' and medical students' perceptions. Write-in responses indicate that some issues may stem from decentralization of programs that utilize multiple hospital sites for OB/GYN clerkships, differences in individual attendings' knowledge and usage of the consent policies, and lack of student presence at the time of obtaining consent.

Clinical implications

This survey indicates that the majority of pelvic EUA consent policies reported by surveyed OB/GYN clerkship directors are aligned with the principles of patient autonomy and respect. However, there remains a need for continued development of policies for explicit consent for pelvic EUA given that not all respondents' MSAHs had policies, in general and for medical students. In addition, many respondents who did attempt to enforce a written, explicit consent policy indicated the desire for more guidance and consistency surrounding a consent form.

Strengths and limitations

To our knowledge, this is the first study assessing policies surrounding consent for medical student performance of pelvic EUA, as reported by the clerkship director. We had a strong response rate of 44.4% of OB/GYN clerkship directors in the United States and our sample also appears representative of the regional groupings we have discussed. Other strengths of this study include the qualitative descriptions of policies and reasoning behind them provided by clerkship directors, affording us nuanced perspectives and explanations for variations. Limitations include potential for response bias and self-selection bias inherent to a survey study design, as those who responded to our survey could be more in tune with current discourse surrounding consent for pelvic EUA performed by medical students.

Although the study asked if there was an explicit consent policy, as opposed to informal or implied consent, explicit consent was not defined. Consequently, respondents may have different interpretations of explicit consent. This survey differentiated between verbal and written consent but did not assess further granularity regarding the form of written consent or documentation of verbal consent.

Future directions

Future work, in conjunction with national leaders in gynecology education such as APGO, should seek to set a gold standard for medical student pelvic EUA consent policies for MSAHs to adopt as they modify or create their own. In addition, future research should investigate the disconnect between clerkship directors' report of student briefing on pelvic EUA consent policies and students' self-reported lack of knowledge of these policies.

Conclusions

This study found that a majority of surveyed U.S. OB/GYN clerkship directors report that their MSAHs have policies surrounding consent for medical students performing pelvic EUA. However, there is considerable variation in these policies and their execution. Research shows that patients and medical students support pelvic EUA if proper consent is obtained, pointing to the ability to properly balance patient bodily autonomy and student education.^5,20 Consent policies for pelvic EUA need to be further strengthened and standardized across MSAHs to protect patients' rights while continuing to teach medical students how to perform the pelvic exam, so that they are prepared to provide adequate health care to patients requiring pelvic examinations in their future careers.

Footnotes

Authors' Contributions

A.M.K.: Conceptualization (equal); writing—original draft (lead). A.P.: Data curation (lead); formal analysis (lead); writing—review and editing (supporting). D.B.: Conceptualization (supporting); writing—review and editing (equal). N.R.J.: Conceptualization (equal); supervision (lead); writing—review and editing (equal).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Appendix Table SA1

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Supplementary Material

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