States crack down on medical students practicing pelvic exams on unconscious patients
COLUMBUS, Ohio — A new batch of states is looking to legislate the level of informed consent required for medical students to perform pelvic exams on unconscious patients for educational purposes.
At least 20 states already have consent laws for this practice. Montana’s governor signed a bill in April, Missouri has legislation that needs the governor’s signature to become law, and Ohio lawmakers are also considering it.
Colorado lawmakers want to go a step further, with Democratic Gov. Jared Polis expected to sign a bill that one bioethicist calls the broadest she’s seen — and says may go too far. The bill would require medical students to be named ahead of time and introduced to patients.
Proponents “see the Colorado bill as a model we hope other states will pass,” said Elizabeth Newman, public policy director at the Colorado Coalition Against Sexual Assault, which favors the legislation.
Opponents of the various bills and laws, who are often doctors, argue that they’re examples of government overreach that could compromise the established trust between patient and provider. It would be better to allow medical associations to make recommendations instead, they say.
It’s difficult to track and quantify how often medical students are asked to perform intimate exams — like pelvic, rectal or prostate exams — on patients who are anesthetized.
During a year of mandatory community service, Mexico’s medical students are often sent to isolated towns where they face violence from cartels.
Typically, a patient signs a number of forms giving broad consent for a range of procedures that might be medically necessary while someone is anesthetized. That can also include consent for educational purposes.
“Most folks just sign them and assume they are going to get the care that they need,” said Colorado Democratic state Rep. Jenny Willford, who co-sponsored the bill.
But patients often aren’t aware that they were examined while unconscious, and if they are, they may fear coming forward, according to Newman. Plus, she said, medical students who could report it are often afraid to raise concerns with superiors who have power over their careers.
Colorado’s bill would require an informed consent process, as well as ensure that the pelvic, breast, rectal or prostate exam is within the scope of the treatment. Practitioners are excepted from the consent process in emergency situations.
The bill breaks new ground in the U.S. by including whistleblower protections for medical students who want to speak out, as well as liability for doctors and hospitals if they don’t follow the consent rules. It’s also unique in requiring that the student performing an exam be named on the consent form and be introduced to the patient before the procedure.
Kayte Spector-Bagdady, a clinical ethicist at the University of Michigan, said Colorado’s proposal is the broadest she’s seen and worries that having to list the names of involved students could limit learning opportunities. Getting consent is typically done days or weeks ahead of time, but students may be unavailable on the day of the procedure — and Colorado’s proposed law wouldn’t allow others to step in and learn, she said.
“We want people to generally know how to take care of women, and [these exams are] a critical component of that,” said Spector-Bagdady, who co-authored a 2019 recommendation by the Assn. of Professors of Gynecology and Obstetrics for such exams. “It’s a balance of respecting the autonomy of our patients and ensuring that the next time they go see a doctor, that doctor knows how to care for them properly.”
That association’s 2019 recommendation, endorsed by major obstetric and gynecological professional associations, says students should perform only pelvic exams that are “explicitly consented to” and “related to the planned procedure.”
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Newman, however, said the mandates are important not only for patients to give complete informed consent, but for medical students to know that the patient has given their consent and to learn the rules governing the consent process.
Alexandra Fountaine, a medical student at Ohio University, was asked to do a pelvic exam on an unconscious female patient on her first day on a rotation at an OhioHealth hospital in Columbus. The request came from the doctor overseeing Fountaine’s training.
She said she didn’t know whether the woman, who was anesthetized for an abdominal surgery that Fountaine said didn’t require a pelvic exam, had given consent for it.
Fountaine did not ask the physician whether the woman had consented, saying that students are taught “to be seen and not heard.” Fountaine said the physician assured her that doing a pelvic exam was fine and “for her education.”
“I initially froze,” said Fountaine, who didn’t end up doing the exam but told the physician she did when her back was turned. The experience led Fountaine to testify in front of an Ohio House committee; her school says it supports students “on their professional journey.”
OhioHealth, which has several teaching hospitals, said in a statement that its policies “regarding patient consent are consistent with current law” and that attending physicians oversee patient exams, which are “a component of the medical education process.”
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There can be an intense disconnect between patient understanding and provider understanding on consent and procedures, said Phoebe Friesen, a bioethicist at McGill University in Montreal whose research helped bring the practice back into focus following the #MeToo movement.
Providers view these unconscious exams as strictly medical or educational; the vagina and other intimate areas are “just another body part,” so specific informed consent isn’t necessary.
But for patients, Friesen believes it’s absolutely necessary. Such exams can leave a patient feeling robbed of their bodily autonomy, or even retraumatize people who have survived sexual assault.
“The solution is so simple,” Friesen said. “Just ask people whether they’re comfortable with this particular practice.”
Jesse Bedayn reported from Denver.
Samantha Hendrickson and Jesse Bedayn are corps members for the Associated Press/Report for America Statehouse News Initiative. Report for America is a nonprofit national service program that places journalists in local newsrooms to report on undercovered issues.
