SALT LAKE CITY — Phoebe Friesen was working with medical students in New York when one approached her with an ethical dilemma. As part of his training, he’d been asked to perform pelvic exams on women who had been anesthetized for other procedures.

The student had complied but was troubled by what he deemed a violation of an unconscious woman's body, as was Friesen.

“I was really shocked when I first encountered this, and pretty horrified, to be honest,” said Friesen, now a postdoctoral fellow in ethics at the University of Oxford who published a paper on the practice in 2018.

Friesen later learned that the practice wasn’t uncommon at teaching hospitals, where medical students, under the supervision of seasoned physicians, assist in patients’ care and gain experience in common procedures.

While patients are typically notified that new doctors will be involved in their care, some may not realize the extent of the involvement, or that signing a "consent to treat" form, which varies by hospital, could allow doctors to perform a medically unnecessary test — such as a pelvic exam.

Yet, as one physician wrote in the journal Health Care Law and Policy, giving pelvic exams under anesthesia is "a practice that is age-old and universally performed."

Twenty-five years ago, a report in the New England Journal of Medicine revealed that 40 percent of teaching hospitals surveyed said they allowed new physicians to practice procedures on people who had just died in the emergency room. Only 10 percent of those hospitals said they first obtained the family’s consent for performing these procedures, which included intubation and catheter insertion.

Some medical professionals justify the practice by saying that, if asked, most families would decline, depriving young doctors of getting real-life training without the possibility of harm.

Pelvic exams, the inspection of a woman's reproductive organs, are better learned by doing than reading about them in a book or watching a computer simulation, physicians say. To some people, however, probing unconscious women's private parts, regardless of motive, is akin to assault, and five states have passed laws explicitly banning the practice.

It is a practice that disproportionately affects poor women, and those with little education and power, says Robin Fretwell Wilson, director of the Family Law and Policy Program at the Illinois College of Law, and a crusader to end the practice in all 50 states.

'An important teaching tool'?

Wilson's efforts, and those of others troubled by the practice, are hampered by twin problems: a lack of women who can share their stories, and a lack of medical students who are willing to talk.

Women who've been used for practice pelvic exams have no way of knowing, unless they wake up with discomfort unrelated to their surgery or have other reasons to be suspicious — like a woman who posted on Twitter that she had long wondered why her feet had been placed in stirrups for abdominal surgery.

“It’s almost impossible for them to know. It doesn’t leave any visible marks; it doesn’t leave scars. The students themselves don’t want to talk about it,” Wilson said.

Medical students who are discomfited by the practice are often uncomfortable questioning a request by senior physicians who supervise them and who may one day write letters of recommendation. There’s also a pervasive sense that the practice is necessary to train good physicians, and thus a social good that outweighs concern about consent.

In several surveys of medical students, including one at the University of Oklahoma, majorities of students said they had performed a pelvic exam on an unconscious woman. Some medical students advocate for and against the practice on internet forums.

Friesen said many young doctors feel moral distress at what they’re being asked to do, and she empathizes with their dilemma. “They are at the bottom of a very strict hierarchy, and they have worked so hard to get where they are."

In her opinion piece in the Journal of Health Care Law and Policy in 2005, Dr. Jennifer Goedken called pelvic exams under anesthesia “an important teaching tool” and noted a significant divide between the public and the medical community, both in understanding what consent forms authorize, and also in the significance of a pelvic exam. To medical students, she argued, an examination of reproductive anatomy should not be any different from an exam of the lungs.

“Do we want the sexual mores of society to place restrictions on the ability of physicians to care for the whole patient? More germane to this discussion, do we want medical students to graduate less prepared to assess the female reproductive system than the rest of the patient?” Goedken, an ob-gyn and associate professor at Emory University School of Medicine in Atlanta, asked.

Goedken contends, however, that consent is important and argues that consent specific to a pelvic exam could be obtained in the physician’s visit prior to surgery.

At the University of Utah’s hospitals and clinics, it’s customary for a physician to introduce any student who is participating in a patient’s care, said Dr. Robert Silver, chair of the Department of Obstetrics and Gynecology. And although Friesen and Wilson have heard anecdotes of multiple students performing a pelvic exam on one woman, Silver said there is typically one student assigned to a patient.

“It’s impossible to learn how to be an effective doctor and an effective clinician without doing procedures. You have to actually render medical care to learn how to do it. You can’t just read about it and then go do it," Silver said.

“At the same time, there needs to be full disclosure to patients and to women about involvement of medical students, and consent. And patients can either agree to do that, or not agree to do that,” he said, adding that teaching hospitals don't allow students or residents to “practice” on patients.

“Everything they do, they’re fully trained to do, and they’re doing it with supervision. And they’re never allowed to do things they’re not 100 percent capable of doing.”

Silver also noted that teaching hospitals are known for their standards, with patients having the benefit of young doctors with up-to-the-minute education paired with senior physicians with decades of experience.

“I would argue that the care rendered (at a teaching hospital) is often superior to places that aren’t teaching institutions,” he said.

In fact, a study published in 2017 in the Journal of the American Medical Association showed that patient outcomes at teaching hospitals were slightly superior to those at non-teaching hospitals. Over 30 days, 8.1 percent of patients died at major teaching hospitals, compared to 9.6 percent at hospitals not affiliated with universities and medical schools, researchers at Harvard T.H. Chan School of Public Health found.

One woman's story

Like Friesen, Wilson was leading a conversation with medical students about ethics when she first learned about the practice nearly two decades ago.

“I’m like ‘Oh, no, that’s not possible, there’s no way in hell we’re doing this without consent.' But then I started to interview faculty members, and they told me, 'We can’t ask women. If we do, they might say no.'”

One woman who would have said no is Jane, a 30-year-old nurse in the Southwest who spoke to the Deseret News but did not want to be identified because she is employed by the hospital where her unauthorized pelvic exam took place two years ago.

She found out about the exam, conducted before her laparoscopic stomach surgery, because a resident mentioned something she had noticed "when we looked at your cervix." When she questioned why the team would have been looking at her cervix during stomach surgery — "It wasn't even in the vicinity" — no one could give her a good answer.

The experience was especially upsetting to this woman because she was sexually assaulted when she was young, and she consulted an attorney about her legal options. She was told that that the practice was not illegal in her state, and since she was not physically hurt, she had no recourse.

"I'm mortified that this is a problem and this is continuing to happen," she said. "If that resident hadn't told me, I would have never had any clue that this had happened to me."

Wilson, the law professor in Illinois, is also frustrated that the practice is occurring 15 years after she testified before the Federal Trade Commission in 2003. Two days after her testimony, the Association of American Medical Colleges issued a policy calling such exams "unethical and unacceptable."

The American College of Obstetricians and Gynecologists later adopted a policy saying that pelvic exams that offer a woman “no personal benefit and are performed solely for teaching purposes” should be performed only with informed consent.

In addition, the group says, "Respect for patient autonomy requires that patients be allowed to choose not to be cared for or treated by learners when this is feasible."

What patients should know

For women who will be undergoing a procedure in a hospital and are concerned about the prospect of an unauthorized exam, the first challenge is to find out whether the medical facility is a teaching hospital. It's obvious when a university name is attached to the facility, such as University of Utah Health or the Medical University of South Carolina Medical Center, but that's not always the case. "A hospital might be hundreds of miles away from a school it's attached to," Wilson said.

The 1,000-plus teaching hospitals in the U.S. represent only 20 percent of U.S. hospitals, according to the American Hospital Association. Generally, large hospitals in cities are teaching hospitals while smaller, community hospitals aren't, but if you're not sure, ask.

At the University of Utah, Silver said patients are often happy to have a medical student assisting in their care, and some research has shown that when asked for consent, a majority of patients are willing to have a newly minted doctor perform a procedure of any kind, whether or not they are conscious for it.

But if you're not comfortable with the idea, tell your physician that you don't consent, either to one specific procedure, or anything involving a student. The hospital will have to honor that request without any change to your level of care.

Ultimately, it's the senior physician, not the hospital, who is responsible for medically unnecessary exams done under anesthesia, Wilson said, but she believes that the American Hospital Association and other organizations could help end the practice by taking strong stands against it, possibly even linking accreditation or Medicaid reimbursements to it.

States could also enact laws that would protect vulnerable patients, as California, Virginia, Hawaii, Illinois, Iowa and Oregon have, she said.

"When we dispense with consent, (the practice of pelvic exams under anesthesia) is going to be distributed to a subset of society while the benefit is enjoyed by all of us. That should give us pause,” she said. “We do want to be thoughtful about how hard it is to train new physicians. We don’t want that to stop.”

But, she said, when asked in advance, and told about the benefits and risks, “Women will consent in large numbers. It won’t reduce to zero the opportunity.”

Even the nurse who had an unauthorized pelvic exam two years ago told the Deseret News she might consider consenting to such an exam if she was about to undergo a procedure involving her reproductive organs, but not an unrelated area of her body.

Otherwise, she said, she's telling her friends to read the fine print when they go into the hospital, as she did for another procedure two weeks ago. "I wrote (on the form), 'No pelvic exam under anesthesia,'" she said.