The ethics of conducting a pelvic exam on an anesthetized woman

I felt a woman’s uterus without her permission. How this happened, and why I thought I had done the right thing at the time, tells us something important about medical education and shows us why doctor/patient interactions often play out like conversations between earthlings and aliens.

To understand my inappropriate actions, you need to know something about the physical exams that we physicians conduct on our patients. More specifically, about the pelvic exams we perform to assess whether a woman’s uterus or ovaries are potentially diseased.

Almost no one enters medical school with any skills at examining patients’ bodies. Consequently, the first time medical students listen to their patients’ hearts, they are lucky to distinguish the proverbial “lub” from the “dub”—what in technical terms we call the S1 and S2 heart sounds. It takes dozens of listenings before medical students are able to recognize the existence of a significant heart murmur, and hundreds more before developing any true expertise and recognizing subtler abnormalities.

And yet, listening to heart sounds pales in comparison to the difficulties of performing expert pelvic examinations. For starters, when a medical student listens to a patient’s heart through a stethoscope, the worst outcome for the patient is the feeling of cold plastic on their chest. An inexpert pelvic examination, on the other hand, can be painful for patients. Add to that the sheer uncomfortableness of an even expertly conducted pelvic exam—this is after all a very private body part being palpated in a manner that even under experienced hands is usually embarrassing and unpleasant—and the very act of practicing a pelvic examination feels like a major intrusion. Any woman willing to let a medical student examine her (before the more experienced doctors inevitably repeat the examination) is doing the medical profession a big favor.

Pelvic examinations differ from heart exams in another important way: they are much more difficult for medical students to glean information from. An experienced physician conducting a pelvic examination can discern whether a woman’s uterus is mal-rotated; whether either of her ovaries is enlarged; and whether palpation of the uterus causes a woman to experience disproportionate discomfort, a reaction that could signal underlying pathology. Yet as the female obstetrician who supervised me during medical school put it to me: “The first dozen pelvic examinations you perform, you won’t feel a uterus, and you definitely won’t feel any ovaries; you will just feel warm.”

Indeed, the pelvic examination can be an acutely uncomfortable portion of the medical encounter for students to learn. We feel nervous probing women’s private parts; we feel embarrassed at failing to glean any information from the exam after patients have been kind enough to let us practice on them.

But we know that we must overcome our nerves and practice. I certainly knew of my need to practice when I walked into the operating room that day, in 1987, gowned and gloved and prepared to assist the surgeon in any way possible, assistance that given my almost complete ignorance of gynecologic surgery largely would amount to holding a retractor during the procedure. (A retractor is a medical instrument used to hold back, say, folds of skin and muscle from the underlying tissues being surgically treated.)

“Student, come over here right now,” the surgeon said. “We need to start the operation, but you need to examine the patient first.”

I needed to examine her? I couldn’t see how that would help anyone. I had never met the patient before, but instead had simply been told to head over to surgical suite number three, or whatever number suite it was, to assist in the operation. I hesitated, which only prompted more urgent beckonings from the surgeon:

“Come over and feel her uterus,” she told me. “She has a large uterine mass. You need to know how to recognize this kind of mass on a pelvic exam.”

My confusion was obvious to see, despite the surgical mask covering the lower half of my face.

“Don’t worry,” the surgeon continued. “She’s anesthetized and won’t feel a thing. Plus, her muscles are totally relaxed from the anesthetics, so you will have a much easier time feeling the anatomy.”

I inserted two fingers from my right hand into her vagina, pressed gently on her abdomen with my left, her uterus now squeezed between my two hands. Yep.  Definite mass. My physical examination skills were now inching towards expertise. My surgical supervisor had helped me develop as a physician.

But of course, she’d also shaped my moral development. I had examined the woman, after all, without her permission. How could the surgeon and I have thought that it was acceptable to do this?  I could only speak for myself. To begin with, I was frantically obsessed with learning my new trade.  In addition, I wanted to impress the surgeon and get a good grade on the rotation. So when I stood there in the O.R. that day, presumably facing a moral dilemma, I barely gave the situation a second thought.

The result of that was that I began thinking that this kind of action was ok. The surgeon, after all, was a wonderful person, committed to medical education and patient care. And I knew that I had nothing but good intentions in examining this patient. There was nothing prurient in my behavior.  I simply wanted to become a better clinician.

But I’m sure if we had woken up that woman and told her what happened, she would have been horrified. The women I have surveyed on this topic say that, while they’d be willing to give permission for medical students to practice pelvic examinations on them, they would feel violated if such practice occurred without their permission.

Moral attitudes are often a function more of our experience than of our training. When some colleagues and I surveyed medical students and asked them how important it was to ask permission before conducting a pelvic exam on an anesthetized woman, brand new medical students almost universally stated that permission was vital but by the time the students finished their OB/GYN rotations three years later, they didn’t see permission as being important anymore. Despite the lectures they’d received about “informed consent” during the first two years of medical school, six weeks of an OB/GYN rotation was enough to change their moral attitudes.

How can an ethics lecture compete with a palpable uterine mass?

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

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  • georgia

    Two years ago I had outpatient fibroid surgery using a new technique – a hysterscopic myomecotomy.. I was clear ‘that I didn’t want to be a teaching case but once they put me under residents and interns apparently joined the procedure and in the surgical notes the anesthesilogist also apparently performed a pelvic exam on me. Later I was told that I didn’t have the option to opt out in a teaching hospital and they assume I only meant when I was still awake.

    When I discovered this after I woke up (the procedure was only supposed to take 20 minutes but took 2 hours as they all were apparently given a chance to learn and it had to be documented in the records. I on the other hand became so upset by the invasion of my body that I developed what felt like vertigo for four days and over the next few months full blown PTSD and I had to be treated a a sexual and traumatic assault center.

    • Sue

      My heart goes out to you Georgia. They put you at risk of great harm due to unnecessary prolongation of your anesthetic. Every second counts and puts you at greater risk of harm. Two hours so they could practice on you! And I use the word “practice” lightly.

      What it amounts to is medicalized rape. In any other setting it would have been called sedation/chemical restraint rendering you helpless so they could digitally rape you and rape you with objects. Also public humiliation, dehumanization, and mental cruelty. No wonder you ended up at a sexual assault center – that is exactly what happened to you. But even more cruel.

      It is more cruel because there are layers of “sanctioning” that make it more difficult for the victim to call it “rape” or even “indecent assault”. The victim experiences it for what it is, for what it feels likes, and for the devastating effects that follow. The “perpetrators” have medicine and the establishment on their side, believing the end justifies the actions. That is why it feels more cruel for the victim – because even though she knows and feels she (or he) has experienced rape, there are few who are going to see it that way.

  • randommomster

    By contrast, so long as it did not impede the performing of the procedure or otherwise endanger my health, go for it. I’d volunteer to be an occasional pelvic exam lab rat if I could figure out how without sounding creepy. I am grateful for the care I have received over the years, and don’t mind paying a little of that forward. My body being used as a teaching example isn’t a sexual thing or a violence/control thing. I would not feel violated.

    • RJones

      Me either, and I am a woman.

  • JeanArt

    I totally agree with Georgia. If this would have happened to me I would have been traumatized also. Why is it so hard to obtain consent before surgery? It speaks volumes to me that a doctor would do this without consent. It seems doctors are suspicious that patients would not consent. If that is the case, how can it possibly be ethical for them to do this knowing the patient would likely object? I understand the need for medical students to learn but it should not come at the price of a patient’s mental stability. How can they justify the practice when a patient can end up with PTSD? There are obviously patients who are willing to have students involved, as the second poster stated, so why not just utilize them? This is NOT patient-centered care. It tells me that the doctors and medical students are more important than the patient. Also disturbing is the comment that medical students going in almost all think this practice is unethical but upon completion of their training, they almost all think it is ok. What does that say about medical school? It almost seems like their ethics were corrupted. It makes me extremely wary of even consenting to anesthesia or sedation; erodes the small amount of trust I have in the system.

  • Molly_Rn

    It takes so little to get her permission and it is the ethical thing to do.

  • doc99

    Quick question: Was there consent for “Examination Under Anesthesia?”

  • EmilyAnon

    In the OR consent form my hospital uses, it states “this is a teaching hospital…people in training, and others, may participate in your care…” I suppose this deliberately vague sentence legally covers any kind of training activity performed on the anesthetized patient by medical students. But a bigger concern for me was who is this group of “others”. My speculation is that they are lay people, but can’t figure out their purpose in my care.

  • pygmygirl

    Why do doctors feel it is ok to so blatantly ignore patient’s informed consent? Would doctors be happy for this sort of thing to happen to their mums, wives, daughters, sisters etc? Why are consent forms so deliberately vague? If this happened to me I would be bringing rape charges against all involved. There are plenty of people happy to let medical students practice on them, and plenty of women who are ok for doctors to practice pelvic exams on them “if they are awake and aware”, so why in God’s name is it ok to force this procedure onto unconscious women who have in no way given their informed consent? I too realize that doctors have to learn, but surely they can learn on informed, willing and conscious patients, or paid women who are happy to do this. Also, how can they possibly “improve their technique” without input from the woman they are examining????? How can they know if it hurts or feels uncomfortable if the woman is passed out on a slab? This makes my blood boil. Would these same doctors feel ok if they had their prostates examined by a bunch of students while they were unconscious and had not given explicit consent? I very much doubt it.

  • MissMeg

    Anesthetized or not, that body on the table belongs to the patient, not the doctor or other medical staff. If you respect the patient, you will ask first.

  • FFP

    Please do not generalize this lack of ethics to all medical doctors. The God syndrome is a disease with increased prevalence among surgeons.

  • katerinahurd

    Do you think that the gender of the anesthetized patient did not contribute to your moral dilemmas? Woud you have a moral dilemma if instead of a pelvic exam you were dealing with an exploratory surgery? I think that informed consent should be independent of the gender of the patient and a physical exam should be conducted percieving the patient, not as a human speciment, but with resfect for the patient.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Permission should have been obtained before performing the exam. I am sure the surgeon obtained permission but it would have been so easy and morally acceptable to inform the patient that doctors in training would be assisting and or present and obtain permission for them as well. Its common decency and courtesy. The patient should have a chance to say no to a student exam. It is their body and their choice. I have students rotate through my practice two afternoons a week. We obtain permission in advance for the students to be part of the process. I tell my patients that this is an opportunity for you to teach a next generation physician how you wish to be treated as a patient. Most of my patients jump at the opportunity to be a teacher. When a patient declines we find something else for the student to do while I see the patient.
    Most schools now have on going ethics and morals instruction as part of the training program. It is a welcome and needed part of training.

    • pygmygirl

      Steven, it’s nice that you have this attitude, but one of my issues is just what is it that you tell the patient they may be having done to them? Is there is an HONEST checklist of all the stuff that students will do, or just a vague and general “do you agree to have students learn stuff on you?”. Having a student, or students, handing you equipment and looking at my appendix while I am unconscious is a lot different to having a student, or students, putting their hands and/or instruments into my vagina. If there was an honest and reliable checklist for all possible things students will be doing and I am allowed to cross out anything I don’t want done to my body is a lot better than a vague “yeah, do whatever you want to my body all in the name of learning”. With such vague wording is it any wonder that so many people don’t trust doctors, and end up distressed with many more problems than what they started with?

    • Sue

      Ethics and morals instruction are excellent additions I agree, but it is
      how you use the ethics and morals that will make a difference. For
      example, is it really necessary to have an ethical debate over whether
      it is right or wrong for a group of people to spread a naked and
      unconscious woman’s legs apart, and insert fingers and a speculum into
      her vagina, without her knowledge or consent? Is it not obvious that it
      is wrong?

      The very fact that this issue is considered debatable speaks volumes about a skewed sense of entitlement and the professions’ view of a woman’s right to privacy and dignity.