Consent requirements for pelvic examinations performed for training purposes

Elaine Gibson; Jocelyn Downie

doi:10.1503/cmaj.110725

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Response to APOG Letter of May 14, 2012
Elaine Gibson

Posted on: 01 June 2012
Response to Consent Requirements for pelvic examinations performed for training purposes as they revisit the issue of consent prior to pelvic examination.
Margaret L. Morris

Posted on: 14 May 2012
Regulatory policy requires specific consent
Robert J. Byrick

Posted on: 28 March 2012

Posted on: (1 June 2012)
Page navigation anchor for Response to APOG Letter of May 14, 2012
Response to APOG Letter of May 14, 2012
Elaine Gibson, Associate Director
Other Contributors:
We are writing in response to the letter to the editor by Margaret Morris on behalf of the Board of the Association of Professors of Obstetrics and Gynaecology of Canada (APOG) dated May 14, 2012, which was in turn a response to our CMAJ article of March 26, 2012. Ms Morris has missed the point of our article. We agree with Ms Morris that some residents conduct pelvic exams solely for therapeutic purposes (i.e., they ar...
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We are writing in response to the letter to the editor by Margaret Morris on behalf of the Board of the Association of Professors of Obstetrics and Gynaecology of Canada (APOG) dated May 14, 2012, which was in turn a response to our CMAJ article of March 26, 2012. Ms Morris has missed the point of our article. We agree with Ms Morris that some residents conduct pelvic exams solely for therapeutic purposes (i.e., they are fully trained in conducting such exams and the only purpose for the exam is the care of the patient) and the Policy Statement does not fail in relation to such residents. However, Ms Morris ignores the fact (explained in our article) that some residents are conducting pelvic exams solely for training purposes, or for a combination of therapeutic and training purposes. It is our considered view (grounded in a careful review of the relevant law) that patients must be asked for explicit consent to a resident's performing a pelvic exam in whole or in part for training purposes. It is on this narrow point that we took issue with the revisions to the SOGC/APOG Policy Statement due to its shift from covering residents and medical students in this context to only covering medical students. We argued, and continue to hold, that residents should either be added back into the Policy Statement in relation to the conduct of pelvic exams for training purposes or a separate policy for residents (requiring disclosure of purpose and explicit consent for such exams) should be developed.
We share Ms Morris' goals of "the best possible care for women in the academic environment" and assuring that "physicians, general practitioners and specialists, and all health professionals responsible for providing optimal health care for women, are adequately trained to have the necessary skills." However, we do not agree that calling for disclosure of training purposes and explicit consent to residents performing pelvic exams for training purposes can be characterized as "needlessly raising anxiety in the public and putting in jeopardy the clinical academic process." In a study conducted at the Calgary Pelvic Floor Disorders Clinic, a majority of women surveyed indicated that they would consent to a pelvic exam for training purposes if asked. Further, even if the result would be fewer patients agreeing to have such exams conducted, this is no justification for overriding legal rights and ignoring ethical responsibilities.
Elaine Gibson and Jocelyn Downie
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Competing Interests: None declared.
Posted on: (14 May 2012)
Page navigation anchor for Response to Consent Requirements for pelvic examinations performed for training purposes as they revisit the issue of consent prior to pelvic examination.
Response to Consent Requirements for pelvic examinations performed for training purposes as they revisit the issue of consent prior to pelvic examination.
Margaret L. Morris, President Academic Professionals in Obstetrics and Gynecology
The board of APOG is writing in response to the article by Ms. Gibson and Ms. Downie, Consent requirements for pelvic examination performed for training purposes as they revisit the issue of consent prior to pelvic examination. As the academic organization responsible for support for the academic missions in undergraduate and postgraduate training in obstetrics and gynecology we have serious concerns about the quality and...
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The board of APOG is writing in response to the article by Ms. Gibson and Ms. Downie, Consent requirements for pelvic examination performed for training purposes as they revisit the issue of consent prior to pelvic examination. As the academic organization responsible for support for the academic missions in undergraduate and postgraduate training in obstetrics and gynecology we have serious concerns about the quality and messages inherent in this article.
The title for the revised guidelines was changed from "medical trainees" to "medical students" to address the concerns raised by the public about medical students performing pelvic examinations on patients. With input from multiple stakeholders including the Society of Obstetricians and Gynecologists of Canada the updated document identifies the role of a medical student as a learner in the important clinical skill of pelvic examination. The new document is patient focused and clearly defines the necessity for informed consent on the part of the medical student and the entire gynecologic surgical team. This document ensures that patients are fully informed about the role of the medical student in their clinical care as a learner and that they may opt out of participation in teaching pelvic examination skills. The guideline ensures that the process and experience for the students and the patient are mutually positive. This seminal work has not yet been done by other medical specialties that require students to learn how to perform pelvic examinations or other intimate exams in order to provide optimal clinical care for both women and men.
The authors expressed concerns about the comprehensiveness of the guideline with regards to the exclusion of residents as medical trainees. Residents are physicians who are qualified medical practitioners and are deemed to have developed their pelvic examination skills to the point where they are able to do this independently as well as offer supervision to other learners in pelvic examination. They are employed under contract by their respective provincial bodies responsible for residency programs, for example PARIM in Manitoba. As qualified physicians residents fall under the ethical obligations set down by our provincial governing bodies, which does include only providing care that the patient has consented to. They will certainly continue to learn and acquire experience in the performance of pelvic examinations as do all obstetrician/gynecologist who have already completed their training. The principle of lifelong learning is very important for all physicians to allow for maintenance of competence.
Finally, the Association of Academic Professional in Obstetrics and Gynecology welcomes input and membership from all interested stakeholders including those from the legal community. We all strive to achieve the best possible are for women in the academic environment while fulfilling our commitment to assure physicians, general practitioners and specialists, and all health professionals responsible for providing optimal health care for women, are adequately trained to have the necessary skills. Ideally this should be done in a safe environment for both the learner and the patient without needlessly raising anxiety in the public and putting in jeopardy the clinical academic process. A collaborative approach between legal colleagues and physicians would be much more productive towards achieving this goal.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (28 March 2012)
Page navigation anchor for Regulatory policy requires specific consent
Regulatory policy requires specific consent
Robert J. Byrick, President
I write on behalf of the College of Physicians and Surgeons of Ontario, in response to the recent article in CMAJ "Consent requirements for pelvic examinations performed for training purposes" (CMAJ, March 26, 2012). We appreciate that the authors of this article were only commenting on new policy guidelines from the Society of Obstetricians and Gynaecologists of Canada and the Association of Professors of Obstetrics and...
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I write on behalf of the College of Physicians and Surgeons of Ontario, in response to the recent article in CMAJ "Consent requirements for pelvic examinations performed for training purposes" (CMAJ, March 26, 2012). We appreciate that the authors of this article were only commenting on new policy guidelines from the Society of Obstetricians and Gynaecologists of Canada and the Association of Professors of Obstetrics and Gynaecology of Canada, and the "flaws" in that policy related to medical residents. They note that their new policy fails to require residents to obtain consent when conducting pelvic examinations for educational purposes. While it may be that this policy does not specifically address resident responsibilities in this area, this College's policy, Professional Responsibilities in Postgraduate Medical Education, explicitly addresses this issue. Our mandate is to regulate physicians in the public interest and our policy clearly states that patients must be given an explanation about the educational purpose of any proposed examination or clinical demonstration and that express consent of the patient must be obtained. Express consent must be obtained whether or not the patient is conscious during the examination. It is also clearly stated that if for any reason, express consent cannot be obtained, the examination cannot be performed. Unfortunately, the authors leave the impression that this is the only policy relevant to this issue. It is critical that patients be assured that in Ontario, and probably in most other provinces, this is not the prevailing policy on this matter. While Societies and Associations should and do have policies that guide member behaviour, regulatory Colleges have the authority to hold physicians accountable in a way not available to those organizations.
Robert Byrick, MD, FRCPC
President, College of Physicians and Surgeons of Ontario
Conflict of Interest:
None declared
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Competing Interests: None declared.