Medical students’ experience of vaginal examinations of anaesthetised women
Prof JD Hutton, Department of Obstetrics and Gynaecology, School of Medicine and Health Sciences, University of Otago, PO Box 7343, Wellington 6242, New Zealand. Email firstname.lastname@example.org
Medical students usually initially learn vaginal examination (VE) by examining consenting anaesthetised women. To assess their experience of this practice, a questionnaire was distributed to all 66 fifth-year students at the Wellington School of Medicine in 2005—53 students responded. Although 184 women were available to approach for consent, only 141 were approached—students claimed insufficient time as their major difficulty. All male students discussed consent with women only in the 2 hours preoperatively, whereas nine (28%) of the female students sought consent earlier on the day or the day before. Of the 114 women asked, 97 gave written consent, but the VE was conducted in only 76 women mostly because the supervising gynaecologist claimed time constraints or was uninterested. Four other women were examined when consent was uncertain and two without consent. All but one of the students considered the experience educationally valuable. Eleven responding students did not perform a VE, and if the 13 nonresponders also did not, more than one-third of students lack this educational opportunity prior to their final year. In conclusion, some students require more commitment to seeking consent, and some gynaecologists may need to better facilitate this learning opportunity so that the consent agreed with the woman and student is more often respected.
Like most medical schools, competency with vaginal examination (VE) is a core requirement for medical students graduating from the University of Otago after a 6-year course. At the University’s Wellington School of Medicine and Health Sciences (UOW), students are initially taught the VE skill in their fifth year during a 5-week obstetrics and gynaecology (O and G) module. After a tutorial that includes role-playing about obtaining consent and practice on pelvic models, each student is rostered to attend one operating session with the goal of conducting a VE on consenting anaesthetised women with the supervising surgeon. The fifth-year students also have other VE opportunities in clinics, and, in the final year, there is a 6-week attachment in O and G when the students assume some clinical responsibility and undertake further VEs supervised by house surgeons and registrars.
Undertaking a VE when a woman is anaesthetised is a common teaching practice, and learning the technical aspects of the procedure may be enhanced because the woman’s muscles are relaxed and the student’s embarrassment is less.1 The involvement of anaesthetised women in this teaching requires their specific consent, although in a recent UK report, 24% of medical students recalled doing educational vaginal or rectal examinations on anaesthetised women without written or oral consent from the woman.2
With increasing numbers of students and women spending less time in hospital preoperatively, the opportunity to approach women about attendance at their operation and to obtain consent to undertake a VE may affect the learning experience. Once VE consent is obtained, there may be intraoperative factors that compromise the learning outcome.
The goal of this study was to determine the opportunity and subsequent experience of students being rostered to attend a theatre session for VE of anaesthetised women.
After a pilot study with 12 medical students in 2004, a questionnaire approved by the New Zealand Central Regional Ethics Committee was distributed to all fifth-year medical students at the UOW in 2005 during their 5-week O and G module. During the attachment, each student was scheduled to attend one operating session conducted by gynaecologists at Wellington Hospital or a satellite hospital 25 km away.
At the end of the initial tutorial about VE, a numbered 18-item questionnaire was given to each student. In the last week of the attachment, students who had not returned their questionnaire were sent a reminder email.
The significance of differences between groups was determined using the chi-square test (with Yates correction if small numbers).
Of the 66 students (34 male and 32 female students), 53 returned questionnaires (response rate 79%), of whom 23 were male students and 30 were female students.
There were 184 women scheduled on the allocated operating lists (mean age 40.1 years, range 18–84 years). Of these women, 141 were approached for consent for a student to attend the operation, usually by the student alone (n = 103), but sometimes by the consultant (n = 33) or jointly (n = 5). Consultants were more likely to ask when the student was male (27/63) than female (11/78) (P < 0.001). When consent was sought by the consultant alone, the student did not meet 17 of these women before operation. The major reasons proffered for not approaching the other 43 women were insufficient time (n = 13) or hospital staff advice that student attendance was inappropriate (e.g. Muslim patient, staff member or nature of operation) (n = 10).
Of 130 women approached about consent on the day of the operation, 74 were approached in the anaesthetic room in the half hour before the operation. All 34 male students sought their written consent in the 2 hours prior to the operation, whereas 9 of the female students sought consent the day before or in the 2- to 5-hour interval prior to operation (P < 0.003).
The perceived time taken to discuss and seek consent was less than 2 minutes with 57 women and 2–5 minutes with a further 51 women.
Of the 141 women approached, 137 gave their approval for the student to at least attend their operation. Besides the 137 operations attended, students attended another 7 operations because they were asked to assist and 2 operations were attended by the student without specific consent because the ‘patient was anaesthetised before (the student) arrived’.
Written consent for the student to conduct a VE was sought from 114 women (78% of attended operations), of whom 17 declined. The rates of consent to VE were not affected by any obvious variable such as the students’ age (P = 0.06), gender (P = 0.30), person requesting consent (P = 0.47) or the age of the woman (P = 0.67). Five students (three male and two female students) did not ask any of their 19 women about VE consent and gave no reason. Reasons other students stated for not seeking consent were ‘inappropriate given nature of operation’ or student’s perception of ‘patient anxiety about (student’s) attendance’.
A VE was subsequently performed by the student on 76 of the 97 women who consented. The major reason proffered by 11 students for not performing a VE when consent had been given was lack of time and/or interest by the surgeon in supervising the student. Three students did not record on their questionnaire whether consent had been obtained with four women in whom VEs were performed, and two students recorded consent as being declined, but an ‘educational’ VE was conducted.
Eleven of the 53 students who returned the survey did not perform any VEs: for 3 of these students, this was because of refusal of consent, and for the other 8 students, the major reason was lack of time to obtain consent.
All but 1 of the 42 students rated the educational value of the VE as ‘valuable’ or ‘very valuable’. If the consultant had asked consent, the student was more likely to rate the value of the examination highly (P = 0.006).
Conclusions consequent upon the satisfying response rate of 79% must be qualified by the relatively small size of this medical school’s fifth-year class.
This study shows that nearly all our students who performed a VE on an anaesthetised woman accorded significant educational value to the experience. Thus, assuming students’ ratings of educational value equate with enhanced learning, the practice of VE of anaesthetised women by medical students in the initial learning of the core skill of VE is worthwhile. It suggests that women can be reassured that their altruism is not misplaced if they agree to a student performing a VE.
The finding that at least 75% of women on the rostered operating schedules were approached about student attendance at their operation suggests adequate opportunity is being made for the students and reflects respect within the clinical service for the importance of medical education. Failure to approach women and subsequently obtain VE consent probably reflects student attitude and/or time organisation. The significant difference in the times when the male and female students approached women is consistent with the recent report of increased male student anxiety about VEs.3 Female students may think more about the implications of consent for VE and plan their time better, whereas male students procrastinate. A reticent student attitude that was not overcome by the practical tutorial or through consultant support preoperatively may also have been why the 5 students (10% of respondents) who had an allocation of 19 women did not seek permission for even one VE.
The 85% consent rate for VE by those women who were asked was higher than in other studies.2–5 This may have been due to different methodologies such as by surveying women’s attitudes to consent in an ambulatory patient setting,5 collecting data retrospectively from students2 or analysing student log books.4 The high rates of consent to attendance and examination in this study may be due to appropriate preselection of who to ask or because altruism and/or an interest in helping to train new doctors are important for many women: the specific tutorial at UOW on VE, including role-playing about obtaining consent, may also have been a factor.
Coercion or patient misunderstanding may explain why many women consented to a VE when asked just before their operation—the timing and situation in the anaesthetic room may have been coercive. Preoperative sedation was not routine during this study, so could not be implicated as a factor affecting judgement. Women may prefer to be asked by a nurse or physician5 and subsequently meet the student.6 For logistic reasons, students at UOW are taught to seek consent for themselves. Most women were asked directly by the student and thus could have found it difficult to refuse consent. Consent obtained by the consultant was associated with possibly half the women not ever meeting the student who examined them: this dishonours ethical principles, codes of practice and most patients’ wishes.6,7
The students’ perceived time to obtain written consent (<5 minutes for 82% of requests) suggests that informed consent for VE is not a time-consuming process.
The ‘student performing an examination without consent’ rate of 9% is considerably lower than that previously reported5 possibly because of the specific tutorial on obtaining consent and staff awareness that there was a survey focusing on consent or the ethical environment.
Contrary to other reports,3–5 there was no gender bias in the ultimate consent for a VE or in the number of examinations performed perhaps because male students received extra support from consultants.
Eleven (21%) of the students who returned the questionnaires did not do a VE because of lack of time and/or commitment within theatre for the educational experience. Some gynaecologists may need to better facilitate this learning opportunity. This may also receive greater priority for students and gynaecologists if the VE experience of anaesthetised women was to become part of the student’s summative assessment. However, if the experience of VE on anaesthetised women is not considered essential to acquiring competency in VE by graduation, further study should be undertaken to determine if and how these students should compensate for this omission in obtaining their competency in VE.
Disclosure of interest
The authors of this study were sometimes the teachers of the students or the supervising gynaecologists.
Contribution to authorship
The principle investigator is Dr J.B. Prof J.D.H. was instrumental in study design and writing the paper. F.L. facilitated clinical coordination and assisted in preparation of the manuscript.
Details of ethics approval
The study was approved by the Central Regional Ethics Committee, New Zealand on 14 December 2004—The National Ethics Advisory Committee Draft Guidelines did not require specific approval for this survey.
This study was funded as part of the contracts of the authors as employees of UOW.