States seek ex­plicit patient con­sent for pelvic ex­ams


Sa­vanah Harsh­barger es­ti­mates she per­formed as many as 10 pelvic ex­ams last year on pa­tients be­fore gy­ne­co­logic surg­eries, feel­ing for fi­broid tu­mors or other ab­nor­mal­i­ties.

The Duke Univer­sity med­i­cal stu­dent said the ex­pe­ri­ence was a revelation.

“It’s pretty em­pow­er­ing to know this is some­thing you can de­tect with a gloved hand in­stead of need­ing an MRI or some more expensive pro­ce­dure,” Harsh­barger said.

What was not al­ways clear to her was whether the pa­tients had agreed ahead of time to have a stu­dent do the exam while they were under anesthesia. The con­sent form, Harsh­barger said, “def­i­nitely does not men­tion any spe­cific things a stu­dent might be doing. It’s fairly vague lan­guage.”

Law­mak­ers in a num­ber of states now want to elim­i­nate any ques­tion about patient con­sent.

Bills in­tro­duced in roughly a dozen states this year would re­quire that women un­der­go­ing gy­ne­co­log­i­cal surg­eries give ex­plicit ap­proval to a pelvic exam be­fore­hand. It’s a step that some med­i­cal ex­perts say is an un­nec­es­sary in­tru­sion into patient care.

Utah’s gover­nor signed a pelvic exam con­sent bill into law ear­lier this year. A bill in New York passed the state Sen­ate this week and is headed to the gover­nor, and the Mary­land Leg­is­la­ture unan­i­mously sent leg­is­la­tion to Gov. Larry Ho­gan, who is ex­pected to sign it.

Mary­land state Del­e­gate Heather Bag­nall said the state’s teach­ing hos­pi­tals have in­formed con­sent as a best prac­tice, but she felt it needed to be made ex­plicit in state law to protect women un­der­go­ing surgery and as an as­sur­ance for med­i­cal stu­dents.

“So we have ba­si­cally just spelled out in no un­cer­tain terms, if a patient is go­ing under anesthesia, if a patient is un­con­scious, that they have to have given con­sent for these ex­ams,” Bag­nall said. “They need this added level of pro­tec­tion, and they need this added level of peace of mind.”

Dur­ing a com­mit­tee hear­ing on the bill, Me­lanie Bell, a board mem­ber for the Mary­land Nurses As­so­ci­a­tion, said there have been times when pa­tients have awak­ened dur­ing the pro­ce­dures and felt vi­o­lated.

“Clin­i­cal ex­pe­ri­ences are nec­es­sary and are im­por­tant, and we must learn in a hands-on environment when we’re stu­dents,” she said. “How­ever, we must treat pa­tients with dig­nity and re­spect.”

A pelvic exam is stan­dard prac­tice be­fore gy­ne­co­logic surg­eries to de­ter­mine the po­si­tion and mo­bil­ity of the or­gans. It in­volves in­sert­ing fin­gers of a gloved hand in the patient’s vagina to feel her uterus and ovaries. Med­i­cal stu­dents some­times do the ex­ams as part of their train­ing.

What’s not clear is how often pa­tients are clearly told of stu­dent in­volve­ment ahead of time.

In gen­eral, the bills in­tro­duced this year would re­quire ex­plicit in­formed con­sent be­fore a med­i­cal stu­dent is al­lowed to per­form a pelvic exam on an anes­thetized patient. Some would re­quire the exam to be re­lated to the planned pro­ce­dure.

Not every­one be­lieves the leg­is­la­tion is nec­es­sary.

Yale Med­i­cal School asked Con­necti­cut law­mak­ers to rely on med­i­cal so­ci­eties to set clear stan­dards des­ig­nat­ing when it’s med­i­cally ap­pro­pri­ate or nec­es­sary to con­duct a pelvic exam on an anes­thetized patient. The school cau­tioned law­mak­ers against leg­is­lat­ing clin­i­cal de­ci­sion-mak­ing and helped per­suade them to shelve the bill.

In New Hamp­shire, the House killed leg­is­la­tion af­ter its health com­mit­tee said it heard ex­ten­sive tes­ti­mony and found that the prac­tice of in­formed con­sent is al­ready in place.

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