When Zahara Heckscher went to George Washington University Hospital last month to have an ovarian cyst removed, she asked her surgeon if medical students would be practicing pelvic exams on her while she was unconscious. She was shocked that the answer was yes.
Medical students, interns and residents at teaching hospitals across the nation routinely learn how to perform such examinations by practicing on patients under anesthesia, medical educators say, and GWU Hospital officials say their program is no exception.
"Everyone I spoke with there acknowledged they normally do that," Heckscher said. "I think it's just such a violation."
So the 38-year-old District woman wrote a note on her consent form forbidding anyone other than her attending physician to perform a pelvic exam on her while she was under anesthesia. On the way to the operating room, she mentioned it to everyone she encountered. "Some agreed with me, and a couple looked at me like I was a little bit crazy, but they said okay," she said.
Heckscher and a growing number of activists say they think women should be advised routinely about the pelvic exam lessons and be given the opportunity to refuse. Gabrielle Lichterman, who recently launched a New York-based group called People Against Non-Consensual Pelvic Exams, says that an overwhelming majority of the nation's 400 teaching hospitals use the generalized consent form as permission to perform the exams, and her group wants federal legislation to ban the practice.
"Women are being victimized," she said. "This is simply unethical, and we want it abolished. I'm very optimistic that this will take under a year."
Peter Ubel, director of the Program for Improving Health Care Decisions at the University of Michigan, co-wrote a study published in the American Journal of Obstetrics and Gynecology about the experiences of 400 Philadelphia medical students trained in the 1990s.
"We don't see a pelvic exam as having any sexual content at all, but that's not how other people perceive it," Ubel said. "There's no way a physician would ever equate a pelvic exam with rape -- there is no rape content to it. But the fact that someone else perceives it that way makes it important."
Ubel found that medical students often examined women who weren't asked for consent, or the students did not know if the woman had been asked. "Students need to learn that they only do these things with permission," he said.
The report said exams without detailed consent on anesthetized patients desensitized doctors about the need for patients to grant consent. Generalized consent forms at teaching hospitals typically authorized participation in patient care by students and residents, without specifying in which procedures they might participate.
Pelvic exams by students are done almost exclusively on obstetrics and gynecology department patients. Similarly, rectal examinations by students are sometimes done on patients undergoing prostate surgery.
Pelvic exams are among the most intimate and sensitive doctor-patient interactions and often cause tension for patients, doctors say. Over the years, OB-GYN staffers have improved the climate in the examining room, adding chaperones and changing the language they use during pelvic exams, said Jehan El-Bayoumi, a residency program director at George Washington.
"As usually is the case, it's the consumers who have driven this as an issue," El-Bayoumi said. "Public pressure has forced physicians to look at how we train students and residents to be more sensitive."
Medical educators at area hospitals say most teaching hospitals allow one or two students to participate in exams of patients under anesthesia along with the attending OB-GYN physician and one or two medical residents. Officials at George Washington, Georgetown University Hospital and Johns Hopkins school of medicine said they follow a similar protocol. Officials at Howard University Hospital and Washington Hospital Center declined to provide details about their programs.
Educational pelvic exams have many defenders in the medical community. Anthony Scialli, director of Georgetown's OB-GYN residency program, said there is no substitute for the operating room lessons learned by examining women who are unconscious. "The abdominal muscles are more relaxed, and the student sees shortly after the exam what the organs look like," he said.
Michael Greger, a doctor from Boston who has lectured to medical students across the nation on the issue, said the voluntary guideline of having one or two students perform the exam is widely ignored.
"If they have five medical students on an OB-GYN rotation, they aren't going to let one do it and not the other four," Greger said. "I never heard of anyone out of some kind of respect for the patient just limiting it to a few."
Nancy Hueppchen, director of the OB-GYN clerkship for medical students at Johns Hopkins University in Baltimore, said there is no way around the need for future doctors to practice pelvic exams, an important clinical skill.
"Would you want a physician graduating from med school or residency making their diagnoses and performing their first pelvic exams after they got out of training?" she said. "I think all of us would probably say no."
Ubel said it usually takes up to 100 pelvic exams before a clinician is adequately skilled. Some medical students say the same principle leads them to perform practice rectal exams in men about to undergo prostate surgery.
In recent years, some medical schools and teaching hospitals have set new policies, especially after journal articles on student pelvic exams were published this year in the Journal of Obstetrics and Gynecology and the British Medical Journal. Now some teaching hospitals, including those affiliated with Harvard medical school, the Medical College of Wisconsin and the University of California at San Francisco, require more explicit discussions with patients about student participation.
John Larsen, George Washington's OB-GYN chairman, said he knows of no instances when a half-dozen medical students have lined up to practice exams on unconscious women. "I have not seen that done since I was in training in New York in the late 1960s," he said. "I don't know if it's going on anyplace in the country, but it might be."
Still, he said he has no plan to amend the hospital's policies. "I'm a policy minimalist," he said.
Dennis O'Leary, president of the Joint Commission on Accreditation of Hospitals -- the nation's primary hospital inspection agency -- said he is amazed the issue was not settled long ago.
"Times have changed, and the issues of privacy and respect for women are really paramount, and they weren't paramount even five years ago," said O'Leary, former clinical affairs dean at George Washington's medical school.
He said he does not favor federal legislation, however. "I'm not sure that congressional intervention is as important as sensitizing the schools, clerkship directors and the students to this problem," he said.
There is an alternative method of teaching Washington area medical students how to perform pelvic exams. The Veterans Affairs Medical Center in the District has hosted about 80 residents a year from the city's three medical schools in a program that brings in a group of "gynecologic training associates" from a women's nonprofit group, Women's Health Consultants. Other hospitals offer their residents the same kind of in-house training from such groups.
Jane Hearren, a registered nurse from Amosville, Va., has worked as a trainer/model for 16 years. "It's not for everybody, but it really isn't difficult," she said. "The students are always respectful and careful. Our group is well trained at making sure we don't get hurt during an exam and being able to stop a student and say, 'Wait, hold on, do this a little differently.' "
Hearren said that a friend who is a nurse practitioner was trained the same way as the medical students, practicing on patients who are unconscious.
"Unfortunately," she said, "I doubt if very many women are giving their consent. If you read most hospitals' consent-to-treat forms, patients pretty much consent to letting doctors do whatever they want in the operating room."
El-Bayoumi said patients will sense changes as a new generation of doctors focuses on making women feel safe and respected.
"In my practice, I have women who have been sexually traumatized or have psychiatric disorders," she said. "This is especially crucial for patients when you're talking about performing an exam that can actually re-traumatize her."
Ubel said avoiding a request for consent is not justified. He said that, when asked, more than half of women agreed to allow students to practice on them.
"Even 50 percent is more than enough," he said.