EDITORIAL

Who really loses when patient rights collide with physician training?

No doubt you've read or heard about the patient at George Washington University Hospital who objected to having a fully supervised medical student examine her while she was under general anesthesia. Such examinations by medical students and residents have long been a mainstay of training young physicians in the fine art of the pelvic exam. There is no other way to do a pelvic exam that is unimpeded by the patient's voluntary and involuntary muscle guarding. However, some patients find the practice so objectionable that they are now adding notes to their surgical consent forms forbidding anyone but the attending physician from performing a pelvic exam while they are under anesthesia. Indeed, a New York-based group called "People Against Non-Consensual Pelvic Exams" has begun to actively lobby for federal legislation to ban such practices.¹

It isn't just lay people who have decried the practice of using patients under anesthesia to introduce young physicians to pelvic anatomy and teach them how to do a bimanual exam. In a recent study, students at five Philadelphia-area medical schools were asked how important it would be to tell a patient that a medical student was going to perform a pelvic examination on her while she was anesthetized.² Students who had already completed an ob/gyn clerkship thought the consent was significantly less important than did those who had not completed a clerkship. The study's authors viewed the change in attitude as inappropriate and urged clerkship directors to ensure that students only perform examinations on patients who have given explicit consent. Dr. Peter Ubel, the principal author and director of the Program for Improving Health Care Decisions at the University of Michigan, was quoted in The Washington Post as saying "There's no way a physician would ever equate a pelvic exam with rape—there is no rape content to it. But the fact that someone else perceives it that way makes it important."³ Yet, Dr. Ubel admitted that it typically takes up to 100 exams to ensure that a clinician is proficient in pelvic examination, leading me to wonder how and where he thinks the students should get their training.

At first glance, it seems very reasonable to contend that a patient's right to autonomy dictates informed consent before medical students or residents perform exams in the operating room, and the American College of Obstetricians and Gynecologists has endorsed the policy.⁴ Indeed, even if legislation is passed banning such examinations or the vast majority of patients start refusing to give consent, there are other ways to teach students how to do pelvic exams. Sophisticated models and gynecologic training associates or "professional" surrogate patients can be used. The bigger risk, however, is that legislation outlawing examination on anesthetized patients or mandating consent may trigger a series of events culminating in irreparable harm to medical students and postgraduate medical education.

The next blow, for example, may be organized patient objections to having students, residents, or fellows present at deliveries or in the operating room. This possibility already worries program directors troubled about the impact of the 80-hour work restriction on residents' and fellows' surgical and obstetrical experience. And what if objections are raised to having students and physicians-in-training round on patients, complete physical examinations, draw blood, or participate at codes? Perhaps some future "People Against Non-Consensual Presentation of their Cases at Rounds or M&M Conferences" will lobby successfully for legislation banning discussion of interesting cases for teaching and quality assurance purposes. Indeed, in many ways, implementation of the 80-hour workweek itself was a reaction to consumer pressure rather than a response to solid evidence that longer work hours are either dangerous to patients or harmful to training. Similarly, the potentially onerous Health Insurance Portability and Accountability Act (HIPAA) regulations are an over-reaction to perceived but completely unsubstantiated threats to patient privacy.

When I was a young physician, patients received much of their care from relatively unsupervised medical students and residents. Large municipal hospitals with enormous indigent patient populations and few attending physicians often were the most sought-after training sites. Whether it was suturing lacerations in the emergency room, performing uncomplicated vaginal deliveries, or repairing episiotomies, students often acquired practical surgical skills with fairly minimal supervision. During their clerkships and externships, students mastered physical diagnosis, medical management, and triage of sick patients. In my day, by their third year in training, ob/gyn residents performed essentially unsupervised cesarean deliveries and chief residents were often the senior operators for hysterectomies. Senior residents routinely placed chest tubes, central lines, and epidural catheters without supervision after observing a couple of placements. Now all of these procedures are carefully supervised by attending physicians, who are present at every delivery and surgery. And even this new, intensely supervised training model is being challenged.

The fact of the matter is that the education of medical students and postgraduates has always depended on a social contract between patient and doctors-in-training. Patients gave the young apprentices access to their bodies and medical histories and permitted them to participate in their medical and surgical care in exchange for helping society gain competently trained physicians. This contract is gradually being undermined by the slow dissolution of the physician-patient relationship as a result of the professional liability crisis, antagonism from consumer groups, and the movement to a "shift" mentality among increasingly overworked and underpaid physicians. Even worse, politicians are exacerbating the potential crisis by appeasing highly vocal activists with passage of expensive, complex, and frequently unworkable regulations. In the short run, regulations designed to "protect" patients from overworked residents and to ensure their privacy may make a small portion of the public happy. In the long run, though, we may find that the newer physicians caring for us are far less well equipped than those who entered practice in years past after superb training. Many changes are needed in American medicine, including tort reform, a rational medical insurance system, more nurses, and cheaper drugs. What we need the most, though, is for the public, policy-makers, and politicians to exercise common sense.

REFERENCES

1. Mission statement. Non-Con: People Against Non-Consensual Pelvic Exams. Available at: http://www.shamexam.org/missionstatement.htm . Accessed July 16, 2003.

2. Ubel PA, Jepson C, Silver-Isentadt A. Don't ask, don't tell: a change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient. Am J Obstet Gynecol. 2003;188:575-579.

3. Goldstein A. Practice vs. Privacy on Pelvic Exams: Med Students' Training Intrusive and Needs Patient Consent, Activists Say. The Washington Post. May 10 2003; A01.

4. ACOG Committee on Ethics. Statement of the ACOG Committee on Ethics Regarding Ethical Implications of Pelvic Examination Training. Available at: http://www.acog.com/from_home/publications/press_releases/nr04-25-03.cfm . Accessed July 16, 2003.

Charles J. Lockwood, MD

Charles J. Lockwood, MD, Editor in Chief, is Anita O'Keefe Young Professor and Chair, Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Conn.

Charles Lockwood. Who really loses when patient rights collide with physician training?

Contemporary Ob/Gyn

Oct. 1, 2003;48:8-11.