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Exams Under Anesthesia (EUAs) are common, but are they a type of assault?

Many doctors-in-training and medical students are asked to perform pelvic exams on anesthetized women during surgeries. Many supervising physicians and surgeons feel they are essential for learning (and for diagnosis and management of patients intraoperatively). But what if a patient didn’t directly consent to students and trainees performing such exams while they are unconscious in the OR?

Bodily autonomy and informed consent are at the center of this issue.

How can patients protect themselves if they DON’T want students doing these exams?

The best approach is to state that you don’t agree to a pelvic exam while unconscious and document it on the consent form. While illegal in a handful of states, EUAs without direct consent are still legal everywhere else…maybe that needs to change?

Awareness is key, so share this video and talk to your loved ones before surgery to make sure their wishes will be known.

Remember: training medical students well is crucial, but doing so in a way that avoids creating moral distress in them (i.e., moral distress caused by forcing them to do pelvics under anesthesia when the patient didn’t directly consent) is clearly possible via the use of appropriate consent processes. Watch the original video here on Facebook and leave your stories and comments. Full Transcript Below!

Video killing your phone battery? Check out the free podcast versions here on iTunes and Soundcloud.

– Okay guys, today I wanna talk about something that’s been in the news lately that’s got a lot of people upset, understandably, and that is unconsented pelvic exams under anesthesia. Let me talk about what this is.

Okay so when I was a medical student, and I was rotating on OBGYN, in order to train us, obviously we would see patients in the clinic with an attending physician or a resident to supervise us, and so if we were learning how to do pelvic exams with a speculum or the bimanual exam, where fingers are placed inside the vagina and you’re feeling the cervix and the internal structures, the ovaries and feeling for masses, you do that with the consent of the patient.

The patient is there, they’re awake, they know you’re there and they purportedly approve that you’re gonna do this and learn from the exam. But another thing happens, and this actually I think happened to me, although I’m trying to remember if we actually consented patients for this, when patients go into surgery in obstetrics, the patient is put under anesthesia, they’re asleep. Now, at this time, when they’re asleep, the surgeon oftentimes will very much benefit from doing a pelvic exam when the patient is asleep.

There are reasons for this. Number one, it’s less painful both physically and psychologically when the patient is under anesthesia. So the structures are softer, there’s more relaxation, you can actually feel better, you have more time and you’re not as concerned about causing discomfort because the patient is under anesthesia. You often need to do that in surgery to feel masses in the vagina, around the cervix, to be able to put a speculum in and actually open it a little bit more than you would when the patient’s awake so you can get a better look at the areas around the cervix and decide what your surgical approach is gonna be.

So by taking a very good look in a way that you can’t do when the patient’s awake, you can make decisions in surgery that will change the outcome. Do I do an abdominal incision, do we go through the vaginal incision, these are major, important decisions.

But the second thing that happens is, while the patient is under anesthesia, a medical student, an intern, a resident, can perform a pelvic exam in order to learn. So they can feel the structures, they can do all the things that the attending can do and actually be guided as to how this is gonna influence the surgery.

Now the obstetricians that I’ve spoken to prior to this show say this is an essential, crucial part of training medical students, residents, house staff etc., in how they’re gonna do their pelvic exams. Now, this is not just one part of the exam. You’re doing quite a few things, let me walk you through it and then we’re gonna talk about consent.

So one of the things you do is a bimanual exam, so fingers in the vaginal vault, feeling the cervix and then pushing on the abdomen to feel the different structures, the ovaries etc., looking for masses different things like that. We won’t go into full detail. The second thing you do though as a bimanual exam is something called a rectovaginal exam. And this is very invasive. So one finger in the rectum, one finger in the vaginal vault and you’re feeling the space between those two structures, for masses, movement, etc. There’s a lot of things you can do, inflammation. And this again is a very invasive procedure and then the third piece of that is the speculum exam where a speculum is inserted and opened and you’re looking inside. So all of that done under anesthesia presumably assuming the anesthesia’s good, the woman doesn’t feel this.

But here’s the rub, if that woman isn’t consented in advance that this is gonna happen, these people are doing an exam on a woman who has not given her permission to have the exam done as an educational tool. So as part of the surgery, the surgeon as part of the consent, has to do the pelvic exam in order to do the surgery right. But that doesn’t mean that medical students, interns, etc., can take turns doing this exam. But that’s exactly what can happen in unconsented exams for teaching purposes.

And when I was a student even though, whether or not we did consent I don’t remember because the resident and the attending filled out the consent, not the student. But then they would say, “Okay Zubin, come and do a pelvic exam now and I want you to feel for this and I want you to walk me through it. Do the rectovaginal, do the speculum exam.” Even that, with the patient unconscious, to me felt like a violation and of course you don’t say no, it’s a hierarchy and you’re listening to the attending physician and you’re feeling, and the attending physician’s a woman and that doesn’t make any difference, you feel deeply uncomfortable doing this on someone who’s asleep, who hasn’t verbally given you their permission to do this.

And it creates a kind of moral distress that you then build a wall around and go, “Well everybody’s doing this, this is just how we train.” So here’s the thing, now it’s becoming public that this is something that can happen, unconsented, under anesthesia pelvic exams. And I think to most people and to me, this is a violation. This is absolutely unconscionable and we cannot allow it to continue. Simple as that. If you’re gonna do an under anesthesia exam for educational purposes, that should be in the consent.

And the gynecologist that I spoke to said, “To a one, that’s exactly what they put in the consent.” These are the people who would be involved in that procedure, do you consent to this? You can say no. Now what I would advocate is this, if it’s causing moral distress to the medical students all right, then something is wrong already. That we could use an unconscious body, somebody’s body and violate them this way, is a deep, deep, deep foundational violation of trust. It violates the patient’s bodily autonomy, their liberty, and it violates the concept of informed consent, that you don’t do things to people without consent.

So here is the call to action. First of all, share this video because a lot of people don’t even know this is happening. If you’re somebody that’s planning to go under anesthesia and by the way if you think this is only women, it’s not, so men can undergo rectal exams, prostate exams, genital exams under anesthesia. So this can apply to men too. If you’re planning to go under anesthesia for any sort of procedure, you should verbally tell the people taking your consent that you do or do not want this sort of exam.

You can write it in your consent as a write in, there’s lots of things you can do to make sure that your wishes are known. All right? The other thing we can do is we can talk about legislation and things like that, honestly I don’t think this should have to be legislated, this should be part of our ethical code as physicians, that we get informed consent where we’re gonna teach.

Now here’s the thing, I am not saying get rid of pelvic exams under anesthesia. For all the reasons I’ve just said, they are essential not just to teaching, but to the care of the woman undergoing surgery. They are essential. So let’s do it right, respectfully, and in keeping with our hippocratic oath to do no harm.

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