Against this backdrop, researchers wondered, "Is completion of an OB/GYN clerkship associated with a decline in the perceived importance of securing permission from patients before conducting pelvic examinations under anesthesia?" According to a Philadelphia-area study published today in the February issue of the American Journal of Obstetrics and Gynecology, researchers at the University of Michigan Health System believe the answer is YES.
"We found that medical students who have not yet done their OB/GYN clerkship place more value on securing consent than do medical students who have completed the OB/GYN clerkship," says author Peter Ubel, M.D., director, U-M Medical School's Program for Improving Health Care Decisions, and associate professor of internal medicine. "The OB/GYN clerkship seems to be the defining event in this erosion, as opposed to gradual erosion throughout students' many clerkships or rotations."
The study looked at questionnaires that were distributed in 1995 to all 4,511 medical students at five Philadelphia area medical schools. Students were asked how important it would be for a patient to be told that a medical student is going to perform a pelvic examination under anesthesia. Researchers tested for associations between completion of an OB/GYN clerkship and attitudes toward pelvic examinations using linear regression to adjust for gender and total amount of clerkship experience.
"Something clearly happens during OB/GYN clerkships that is associated with students placing less importance on consent for pelvic examinations under anesthesia," says Ubel, who was on the faculty at the University of Pennsylvania's Center for Bioethics at the time the study was conducted.
The experiences of two of the authors as medical students suggest that consent is either not routinely obtained for educational pelvic examinations performed by medical students in the operating room or, at best, somewhat murky.
"In our medical student experiences, we were unclear whether the patients we were asked to examine had given explicit consent to be examined. The study suggests that similar experiences are associated with a decline in the importance students place on seeking permission for such examinations," Ubel says.
At the U-M Health System, however, policy and practice are in unison, and patient consent is the norm.
"It is the nature of education that students learn both by observation and by doing. We place a great value on developing a sense of professionalism in our medical students, and we expect faculty to follow policies about informed consent so medical students can emulate what they see in a positive way," says Maya Hammoud, M.D., clerkship director, U-M Department of Obstetrics and Gynecology. "In addition, here at UMHS, patients are informed that pelvic examination under anesthesia are conducted when necessary to assure safer performance of the operation, and that medical students may participate in these examinations."
Ubel and his colleagues believe the data may reflect students' strategies for coping with the knowledge that they participated in an activity that, if discovered, could cause patients to feel violated. As a result, some students may simply deny the importance of obtaining consent in the first place.
"Medical educators can remedy this decline in students' attitudes toward pelvic examinations under anesthesia by making sure that students perform such examinations only on patients who have explicitly given their consent. Students will still have a good learning experience, and they'll also learn important lessons about medical professionalism and ethics," Ubel concludes.
Additional Contact:
Krista Hopson, khopson@umich.edu
734-764-2220