Before Kathleen Ackert started her rotations, she was alarmed when she heard tales of medical students practicing pelvic exams on unconscious patients.

“As a person who plans to spend her career delivering babies, performing surgeries, advocating for women, transgender folks and reproductive rights, it was horrifying to me to hear these stories,” said Ackert, now a 25-year-old fourth-year medical student at the Philadelphia College of Osteopathic Medicine.

But Ackert was relieved to discover that the practice, which has been reported widely, has faded considerably. During her rotations, Ackert performed dozens of pelvic exams, but she met the patient and obtained informed consent in all but one case.

She was asked to assist in a vaginal hysterectomy, but the woman already had been anesthetized. “I wavered and said, ‘You know I didn’t meet her ahead of time, and I get nervous about doing that because of what’s been going on in the media and [I’m] nervous that I would be disrespecting someone’s body,’” Ackert said.

In the end, Ackert’s supervisor convinced her that the exam was necessary for the patient’s care. But her reticence illustrates just how much this aspect of medical training has changed from the days when doing pelvic exams on unconscious women was an accepted part of medical training.

Numerous medical groups have declared that explicit patient consent is necessary whenever possible before a pelvic exam. Last March, the Association of Professors of Gynecology and Obstetrics released a statement recommending that students perform pelvic exams only when the patient provides “explicit consent” and when the exam is “clinically relevant.”

Some states also have banned the practice if done for educational purposes, not patient care. In Pennsylvania, two female legislators from the Philadelphia area plan to introduce a bill that would require consent, although it would have an exception for exams that are deemed to be “within the scope of care.” Eleven other states have such laws.

“We just want to create more awareness and have a more specific consent form for this,” said Montgomery County State Sen. Katie Muth, who is co-sponsoring the bill with a fellow Democrat, Sen. Maria Collett, whose district includes Montgomery and Bucks Counties. “We don’t want secret procedures happening."

During pelvic exams, doctors use their fingers to check the cervix, uterus, ovaries, and sometimes rectum for any abnormalities, such as fibroids. The checks are typically done while patients are conscious and consenting, such as during a visit to a gynecologist’s office.

As the insistence on patient consent has grown, so have questions about the need for routine pelvic exams, once an annual ritual for American women of child-bearing age and beyond. In 2016, the U.S. Preventive Services Task Force found that there isn’t enough evidence to justify doing the invasive procedure annually on healthy women who aren’t pregnant.

Some medical training programs teach students pelvic exams with the help of gynecological teaching associates — women who teach medical students, nurses and sexual-assault examiners how to conduct comfortable pelvic exams by acting as the patient and giving feedback in real time. Other programs require doctors to describe the pelvic exam and ask for consent from patients while they are awake; others detail it in a consent form that patients sign before surgeries.

Both the Lewis Katz School of Medicine at Temple University and the Perelman School of Medicine at the University of Pennsylvania provide patients with a consent form that explains how medical students may participate in their care during surgeries, including a pelvic exam for educational purposes. Medical students conducting the exam at Temple must confirm with their attending that an anesthetized patient has consented, and Penn requires such consent in writing.

“Respect for all patients is a cornerstone of medical training in the Perelman School of Medicine," a Penn Medicine spokesperson wrote in an email.

Thomas Jefferson University’s Sidney Kimmel Medical College has informed consent policies in place.

The Philadelphia College of Osteopathic Medicine requires students to “abide by the policies of the hospitals" where they are doing their rotations,” a spokesperson wrote in an email.

‘An opportunity to build trust’

Though far less common than they once were, pelvic exams performed without consent may still happen.

Elle magazine conducted a survey last spring and found that out of 101 medical students from seven major American medical schools, 92% had performed a pelvic exam on an anesthetized female patient, and 61% reported that they did not have explicit consent when doing so. A now out-of-date survey from 2005 medical students at the University of Oklahoma showed that a majority of respondents had performed pelvic exams on patients under anesthesia for gynecological surgery. Three quarters of respondents believed that patients had not consented to those exams.

Though today’s students, such as Ackert, learn from the start about the importance of patient consent and open communication, this is a fairly recent change in attitude. In a 2003 survey of 400 Philadelphia medical students by a former University of Pennsylvania medical student, researchers found that after completing ob-gyn training, 24% of students said consent was unimportant.

Getting consent, doctors say, usually is not difficult when patients understand fully what’s happening with their care, and why.

Rachael Polis, a pediatric and adolescent gynecologist for Crozer-Keystone Health System, said that she approaches consent as “not just a piece of paper, but very much a process." Before a surgery, Polis, who works with residents but not medical students, educates the patient, and often family members, on what the surgery will entail and who is going to be in the operating room. On the day of the procedure, she said, the patient meets the entire care team, including the residents who will be assisting her.

“Residents and students need this experience,” Polis said. “It’s part of becoming a future physician, learning by practicing. But I’ve found that the more you explain, the more you talk about what’s happening, the more comfortable patients are. Discussing all of this ahead of time and getting their consent is really important ethically.”

A 2003 study by Robert Berry, then the ob-gyn residency director at the University of Massachusetts Medical School, found that more than 80% of patients agreed to let a student examine them if they were asked in advance and didn’t believe that they were being pressured. Berry also found that patients preferred being asked by nurses instead of doctors.

Ackert said that she has learned to obtain patient consent from such teachers as the attending physician who showed patients pictures so they would understand exactly what would be removed during a hysterectomy. This physician also told patients exactly who would be scrubbed in with her during the surgery ⁠— including usually a resident and a medical student.

“I have also seen consent done poorly,” Ackert said. “A doctor shoving a piece of paper in the face of someone and saying, ‘Sign this.’”

Ackert said she wants to be the kind of doctor who knows how to communicate with patients and answer all of their questions.

“You have the right to know what’s happening to your body,” Ackert said.

Muth, the state senator, is optimistic that health-care providers will support this bill once it’s introduced.

“If you’re not doing anything wrong, you’re not going to be fearful of legislation,” she said. “Doctors should want to be honest with their patients. It’s an opportunity to build trust between patients and health-care providers.”