Prevalence of pelvic examinations on anesthetized patients without informed consent
Rachel Cutting, Varsha Reddy, Sneha Polam, Nicole Neiman, David Manna
Journal of Osteopathic Medicine, 7 October 2024
Open Access
Abstract
Context
The pelvic examination is a fundamental tool for the evaluation and diagnosis of women’s health conditions and an important skill for all medical students to learn as future physicians for the early detection of treatable conditions such as infection or cancer. Although the American College of Obstetricians and Gynecologists (ACOG) asserts that performing pelvic examinations under anesthesia for educational purposes should only occur if the patient provides explicit and informed consent, there still have been reports of medical students performing pelvic examinations on anesthetized patients across the country, and many states are now starting to pass bills requiring informed patient consents to conduct pelvic examinations under anesthesia.
Objectives
The objectives of this study are to evaluate the prevalence of pelvic examinations performed by osteopathic medical students on anesthetized patients without consent while fulfilling their third-year OB-GYN clerkship requirements.
Methods
The survey was administered and distributed to all osteopathic medical schools in the country via the Student Osteopathic Medical Association’s (SOMA’s) chapter emails, outreach emails, and SOMA’s social media accounts to collect data. Inclusion criteria included third- or fourth-year osteopathic medical students who completed their OB-GYN clerkship rotations when taking the survey. The exclusion criteria included any osteopathic medical student who had not completed their OB-GYN clerkship rotation. We utilized descriptive analysis to summarize the final data.
Results
We received 310 responses. The final number of responses was 291 after meeting the exclusion criteria. Most osteopathic medical students (94.2 %, n=274) considered the practice of performing pelvic examinations on anesthetized patients without their explicit consent unethical. Among the participants, 40.9 % (n=119) admitted to performing pelvic examinations on patients under anesthesia while on OB-GYN rotations, but most of them (57.1 %, n=68) did so without obtaining prior consent from the patients. Notably, the number of pelvic examinations performed by medical students on patients under anesthesia ranged widely from 1 to 25 with a median number of 10. Moreover, 58.9 % (n=70) indicated that they had not been properly educated to obtain specific consent before performing pelvic examinations under anesthesia. Many participants cited efficiency of practice, lack of policy awareness and personal education by medical students, and failure to refuse to perform pelvic examinations on anesthetized patients as trainees when asked by their seniors or preceptors.
Conclusions
This study demonstrates that although most osteopathic medical students consider performing pelvic examinations on anesthetized patients unethical, many still admit to practicing pelvic examinations on patients under anesthesia, while on OB-GYN rotations for efficiency of practice, lack of policy awareness and personal education, and being in unique positions in which grades are determined by seniors and preceptors for their willingness to do what is asked even if the practice does not align with their conviction. This study highlights the importance of ongoing research and implementation of policies at institutional and state levels that will procure the value of pelvic examinations while protecting and upholding the ethics of patients’ rights and autonomy of medical students.

The Impact of Obtaining Explicit Informed Consent for Medical Student Participation in the Pelvic Exam Under Anesthesia: A Qualitative Interview Study
Research Article
Hannah C Milad, Katie Watson, Patrick F Eucalitto, Ricky Hill, Alithia Zamantakis, Marlise Jeanne Pierre Wright, Adaeze A Emeka, Susan Tsai, Susan Goldsmit, Magdy P Milad
International Journal on Obstetrics and Gynecology, 26 September 2024
Open Access
Abstract
The pelvic exam under anesthesia (EUA) is an essential step in gynecologic surgery. Attending, fellow, and/or resident physicians utilize exam findings for surgical planning. Afterwards, medical students often perform this exam for their own learning; the student exam provides no direct clinical benefit to patients. Historically, consent for trainee EUAs was embedded within the surgical consent form. At one urban academic medical center, a written consent form specifically for medical student participation in the pelvic EUA was introduced. Our study examines patient, physician, and operating room (OR) staff perceptions of this new, explicit consent process between May 2021 and May 2023. Thirty-one (31) subjects including patients, OR staff, and physicians were interviewed and Northwestern University IRB approval was obtained. Our data suggest patients appreciated being asked to explicitly consent to or refuse the student pelvic EUA and having a dedicated consent form left them with a positive feeling about the hospital and their healthcare providers. OR staff and physicians agreed that the student pelvic EUA is necessary and almost all supported an explicit consent form. Physicians did not find the additional consent form burdensome and noted only a modest decline in learning opportunities. Patients and healthcare providers agreed that requiring explicit written consent for the student pelvic EUA respected patient autonomy, improved healthcare quality, and caused minimal disruption to medical education. Our data support the use of an explicit written consent form for student participation in the pelvic exam under anesthesia as standard practice.

Reevaluating Informed Consent: Integrating Shared Decision-Making into Spinal Surgery for Better Patient Outcomes
Jeffrey N. Wang, Mohamed A. Elhakeem, Matthew J. Mesimer, Paul G. Mastrokostas, Salman Ahmad, Tim Reed, Brandon Klein, Lucas E. Bartlett, Adam D. Bitterman, Andrew Megas
Global Spine Journal, 26 October 2024
Abstract
Study Design
Narrative review.
Objectives
The objectives of this study were to answer the following questions: (1) What is the quality of informed consent in spine surgery, including both neurosurgery and orthopaedic spine surgery? (2) What limitations impede the ability of surgeons to engage in effective shared decision-making (SDM) and obtain adequate informed consent? (3) What strategies and solutions may improve the quality of informed consent and SDM? (4) What factors decrease the incidence of litigation in spine surgery?
Methods
N/A.
Results
SDM is a collaborative process where patients are involved in their treatment choices through open communication about risks, alternatives, and postoperative expectations. Informed consent is a vital component of this process, ensuring that patients are fully informed and empowered to make decisions based on their values and preferences. This review highlights the current state of informed consent within the context of SDM in spine surgery and explores how enhancing this process can improve patient outcomes, reduce dissatisfaction, and decrease litigation. By emphasizing patient autonomy and improving the quality of risk communication, SDM fosters better physician-patient relationships and more positive clinical outcomes.
Conclusions
Orthopaedic surgery and neurosurgery are highly litigated specialties, with failure to obtain informed consent frequently cited in lawsuits. These legal challenges are costly and time-consuming for both physicians and patients. Integrating SDM into the informed consent process can help mitigate these issues, leading to improved patient satisfaction and fewer legal disputes.

Development and early Evaluation of a novel tool for assessment of individualised risk tolerance during surgical consent
Research Article
James Booker, Jack Penn, Nicola Newall, David Rowland, Siddharth Sinha, Hani J Marcus
British Journal of Neurosurgery, 17 October 2024
Abstract
Purpose
The legal interpretation of consent has transitioned over the last decade. Surgeons must identify what patients value to individualise surgical consent. This presents a considerable challenge during busy ward rounds or outpatient clinics. We aimed to develop and evaluate a novel risk tolerance tool to aid surgical consent.
Methods
This prospective, longitudinal cohort study evaluated the views of adult, elective surgical patients from a single centre. Attitudes to the existing surgical consent process were assessed (n = 48) and responses underwent thematic analysis. From these responses and a stakeholder focus group, a novel risk tolerance tool was developed. The risk tool was evaluated using questionnaires in 25 pre-operative patients. Post-operatively, the same cohort were followed-up with a telephone clinic 6–8 weeks after discharge.
Results
Overall patients were satisfied with the current consent process, but negative themes emerged including that it is generalised, impersonal, and time pressured. The developed risk tool contained six domains: death, pain, loss of physical function, loss of cognitive function, need for repeat medical interventions, and social disability. Loss of physical function (mean = 34.0, SD = 12.8) and loss of cognitive function (mean = 34.0, SD = 6.1) had lowest risk tolerance, and need for repeat medical interventions (mean = 18.8, SD = 10.9) had the highest risk tolerance. Thirteen (93%) patients had a positive experience of the consent process vs 85% of patients in pre-consent tool cohort.
Conclusions
The tool demonstrated good patient acceptability and patient reported experience. The tool gathered data that may enhance understanding of patient risk tolerance and personalise the surgical consent process.