Fw: We're in today's Wall Street Journal, about women patients privacy rights, page B1

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----- Original Message ----- From: Zuckerman

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Sent: Wednesday, March 12, 2003 7:37 PM

Subject: We're in today's Wall Street Journal, about women patients privacy rights, page B1

We received a call from a Wall Street Journal reporter who was doing a story about medical students doing pelvic exams while patients were unconscious, without the patient being asked for consent. She had come across my article on informed consent for breast cancer patients.

I had not heard of this before, but was appalled to hear that med students were being taught to do pelvic exams on unconscious patients prior to their surgery for unrelated problems.

A copy of the article is below:

Doctor Training On Unconscious Sparks Criticism By Audrey Warren 12 March 2003 The Wall Street Journal B1

UNDER CRITICISM that patient rights are being trampled, medical schools are beginning to change a common practice of allowing students to practice pelvic examinations on anesthetized women without their knowledge.

Medical students often are allowed by their training physicians to practice the exams in the operating room when the patient is unconscious and hasn't given explicit consent, researchers and doctors say. It's standard practice for a surgeon to do a pelvic exam before an operation, performed by inserting two fingers in the vagina to locate and examine the woman's ovaries. The primary physician usually does the exam first, then students may repeat the exam for training purposes.

Several recent studies have raised concerns about the practice and question whether schools are adequately teaching students about patient rights. A January study in the British Medical Journal found that third-year students at an English medical school didn't know whether consent was obtained for half the pelvic examinations they performed. A University of Toronto study published in 2001 found 47% of 108 students felt pressured to act unethically in a clinical setting and cited practicing gynecological and other procedures on unconscious patients without prior consent as a particular cause of concern.

A study published last month in the American Journal of Obstetrics and Gynecology found that by the time students completed obstetrics and gynecology training at five Philadelphia hospitals, they considered patient consent significantly less important than did students who hadn't completed their training. Among the 401 medical students who participated in the study, 90% acknowledged performing a pelvic exam on an anesthetized patient. "It's highly unlikely students gained consent in those cases," says Ari Silver-Isenstadt, co-author of the Philadelphia study, which took place in 1995.

In response to the Philadelphia study, the University of Pennsylvania's medical school faculty was asked by the director of the OB/GYN department to obtain specific patient consent for exams under anesthesia, although they aren't required to explain the extent of student involvement. "Maybe we have to be more specific," concedes Deborah Driscoll, the school's OB-GYN clerkship director. Penn, like many schools, also has a surrogate patient programs where volunteers are paid to allow students to practice a range of procedures such as examination and inserting intravenous lines.

"You might imagine students watching, but you wouldn't imagine laying in a room with a bunch of medical students performing medical exams on you," says Zuckerman, president of the National Center for Policy Research for Women & Families. "It feels like an invasion of privacy."

Medical students say it is difficult to know if the physician has gained consent for them from an unconscious patient. "As a student you really assume that everything is being taken care of," says Ashish Ranpura, a first year medical student at the Medical College of Ohio in Toledo.

Students are reluctant to ask the doctor -- who grades them -- lest it suggest they are questioning the quality of care the physician is providing. It can be "a great way to get a lower grade on your clinical rotation," Mr. Ranpura says, though he added some doctors will gain respect for a student who questions.

Harvard medical school initiated changes several years ago after students complained to Federman, the senior dean of clinical teaching, that patients weren't being asked properly before practice pelvic exams. The school enunciated a new policy, whereby physicians and students meet with patients before surgery to ask for consent. The pressure to adopt this type of policy has only built up in the past decade, Dr. Federman says. "The women's movement, as part of asserting control over your own body, has had a lot to do with it."

Dr. Silver-Isenstadt, the Philadelphia study's co-author and a pediatrician at lin Square Hospital Center in Baltimore, began questioning pelvic exams on unconscious patients as a medical student in OB-GYN training at the University of Pennsylvania medical school 10 years ago. "It's very uncomfortable to feel like you're doing something wrong," he says.

A number of hospitals say their current consent procedures are adequate. The Committee on Ethics at the American College of Obstetricians and Gynecologists defines informed consent as "a process that includes ongoing shared information" and "communication." Yet, many hospital admittance forms simply contain broad statements such as "services may be performed by individuals selected and deemed qualified" or patients "may be visited and attended by students or residents of various disciplines." The Geffen School of Medicine at the University of California at Los Angeles tells patients "residents, interns, medical students . . . may participate" in care as part of the University's medical education programs. The hospital doesn't specify whether that care is for the patient's direct benefit.

Women can refuse to allow students to practice on them, but it isn't appropriate to go into a training hospital and not expect students to be there when it is the forum set aside for that purpose, says a Speyer, president of OBGYN.Net, a site that addresses women's healthcare issues.

But many patients just want to be explicitly asked to be a teaching subject. "I don't think the students have a right to perform something as personally invasive as a pelvic exam without the patient's explicit consent to that particular act," says Steeves from Nashua, N.H., who granted consent for a student to give her a pelvic exam.

Dignam, who is responsible for OB-GYN clerkships at UCLA, says physicians meet with patients after surgery but don't discuss student participation. "I'm reasonably certain that patients know medical students will be participating," he says, adding, "it's pretty much covered in an overall consent form."

Not all doctors allow the practice without explicit consent first but some defend it as harmless and say asking for consent would make it more likely that patients would say no, denying students a crucial part of their training.

However, research shows many women wouldn't object to being examined by students anyway, says Ubel, the Philadelphia study's co-author. That suggests that if hospitals sought explicit patient consent, they wouldn't find a sharp drop in practice subjects.