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andre picard's second opinion

Editor's note: In September, 2010, following the publication of this story, the Society of Obstetricians and Gynaecologists of Canada and the Association of Professors of Obstetrics and Gynaecology of Canada revised its policy on pelvic exams performed by medical students to explicitly say that consent is required.

Imagine that you are undergoing a fairly routine surgery - say, removal of uterine fibroids or hysterectomy. During or right after the procedure, while you are still under anesthesia, a group of medical students parades into the operating room and they perform gynecological exams (unrelated to the surgery) without your knowledge.

Do you consider this okay, or an outrageous violation of your rights?

Regardless of your feelings, you should be aware that this is standard procedure in many Canadian teaching hospitals.

Medical students routinely practice doing internal pelvic examinations while surgery patients are unconscious, and without getting specific consent, at least in Canada.

Guidelines in the United States and Britain say specific consent is required but, by contrast, Canadian guidelines state that pelvic examination by trainees is "implicit."

The practice - one of those dirty little secrets of medicine - has been exposed in a thoughtful, professional manner by a young doctor.

The story goes back to 2007 when Sara Wainberg was a medical student at McMaster University. Her younger brother Daniel, also studying to be a doctor, phoned for advice: As part of his rotation in obstetrics and gynecology, he had been asked to perform a pelvic exam on a woman who was under anesthetic. He refused, saying doing so without consent would be unethical.

"It got me thinking," Sara Wainberg said. "I had done this numerous times in my training and it had never occurred to me that it might be unethical."

She polled her fellow students and found 72 per cent had also done exams on unconscious patients, without consent, confirming that it is routine.

It is essential for medical students to learn basic techniques, including pelvic examination, in well supervised settings.

The long-standing argument in favour of allowing these exams to be done on surgery patients is that it provides a unique opportunity for students to practice the delicate, invasive examination without causing the woman pain or embarrassment.

There is also an assumption that women would never accept pelvic exams by students while conscious so sneaking them in, while not ideal, is acceptable.

When Dr. Wainberg took a position as a resident at Foothills Hospital in Calgary, she decided to study the issue further. She and fellow researchers polled 102 women who were patients at the Calgary Pelvic Floor Disorders Clinic.

The results - reported in The Medical Post and in the Journal of Obstetrics and Gynecology - are as fascinating as they are troubling.

Dr. Wainberg and her team found that fewer than one in five women were aware that a student might do a pelvic exam in the operating room. At the same time, 72 per cent expected to be asked for consent before such an exam was done.

The patients - unlike medical educators - seem to be quite clear on the concept of informed consent.

You don't probe, poke or otherwise invade the orifices of a patient without their permission, regardless of how educational it might be. Period.

The most intriguing part of the survey, though, is that it showed that women are quite willing to undergo these gynecological exams - if they're asked.

Sixty-two per cent of respondents said they would consent to medical students doing pelvic exams, and an additional 5 per cent said "yes" but only if a female student was doing the exam.

This lays to rest the notion that it would be impossible for medical students to get this training unless they were doing it in the current surreptitious, unethical manner.

But let's be clear: Even if all the women surveyed had rejected exams by medical students, the current approach would still be wrong.

There are other ways to do this training, using simulation models, paid volunteers and consenting patients in other settings such as clinics.

Patients have a right to say "No." They are not merely a collection of body parts to be practised on. Patients are due respect and ethical treatment, whether they are awake or anesthetized, and no matter how potentially embarrassing the procedure may be.

The research done by Dr. Wainberg and her colleagues, in passing, exposed something else important: Patients have very little idea what goes on in the operating room. Most have no idea that, in addition to the surgeon and nurses, medical residents or medical students may be present and may even participate actively.

This is the result of a failure to communicate. It is also a striking example of a lingering bit of paternalism that is still all-too-present in medical culture - this notion that "we do the surgery and the details are none of your business."

"It's definitely the patient's business who does what to them," Dr. Wainberg said. "They have to be informed and they have to give consent."

In fact, if she was starting over again as a medical student and was asked to perform a pelvic exam, Dr. Wainberg has no doubt she would refuse.

So too should every medical student and every teacher.

A good doctor does not merely possess good technical skills, she or he must behave ethically and treat patients with the utmost respect.

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