“Do a pelvic exam,” the surgeon said casually.
The patient lying before me was about to undergo a hysterectomy. Did she know a student would be performing an unnecessary pelvic exam while she was unconscious?
I tried to think of something to say.
Did she consent? It was my first day meeting the surgeon, and I didn’t want to imply she was potentially being unethical. I felt uncomfortable, but I also didn’t want to come off as lacking initiative or even worse, challenging authority.
On this first week of clinical rotations as a medical student, my fears surrounding evaluation were nothing short of pathological. I was scared to ask to use the bathroom.
I panicked, said nothing, put lubricant on my glove, and did a pelvic exam.
Scenarios like this occur regularly for medical trainees. It’s been estimated that hundreds of thousands of unconsented pelvic exams occur each year in the U.S. As a result, the Department of Health and Human Services passed guidance in 2024 requiring written consent for sensitive exams, though it remains unclear to what extent health systems have implemented the changes.
Medical students rotate through the core medical specialties — internal medicine, surgery, psychiatry — during their last two years of training. In these clinical rotations, students work and practice in hospitals and clinics where they are supervised and graded by attending physicians. When I started my journey to become a doctor, I didn’t anticipate the pressure to conform and impress these preceptors. Training future doctors to become genuine advocates for their patients means teaching them to focus their concerns on patients, not just preceptors.
To address this, patients should serve as evaluators, too, and the medical school curriculum should emphasize and expect students to advocate for patients.
As it stands, medical trainees are afraid to speak up for what they believe is right. A 2019 study found that more than half of medical students didn’t voice their concerns for patients in situations they deemed to be “critical”. Undoubtedly, most students enter medicine with the goal of taking care of and serving patients. Yet the hierarchical training structure causes students to stay quiet in situations they know could be harmful for patients.
After years of collaborating with countless preceptors, I now know that some doctors would have accepted and even encouraged my willingness to speak up in the operating room. Others, however, would not have. Some may handwave my confession as cowardice, but I suspect they’ve never been a terrified newcomer in a bustling operating room.
Supervision is a necessary part of training, but it should inform and guide, not serve as an ever-present eye of scrutiny. Research suggests that students feel “discomfort” regarding their clinical encounters. They may perceive their preceptors as engaging in assessment, not observation, which leads to inauthentic encounters. That doesn’t help the student or the patient.
Depending on the rotation, patients could be identified as evaluators based on a structure that focuses less on aspects like medical knowledge and more on indicators of true professionalism. This shifts the student’s attention back to the human beings in front of them. Some universities have already begun implementing various versions of this, though it is by no means the norm in the formal curriculum.
Selected patients could be given a short evaluation form that focuses on characteristics like bedside manner, nonverbal communication, and avoidance of medical jargon. After an encounter, the patient could then debrief alone with the student to discuss the evaluation without the presence of an attending, allowing students to focus solely on the perspective of their patients.
Some may criticize this approach, as patients wouldn’t technically be “trained” how to best evaluate medical students. However, it’s worth noting that many attending physicians are never formally trained either. Regardless, it may be more beneficial for learners to have the genuine subjective perspective of patients who don’t have a medical background, especially because ultimately this is who we are in training to serve in the future.
While we’re at it, medical schools could also update observed structured clinical examinations, or OSCEs, a near-universal aspect of training during which students see patient-actors in a recorded room for a mock encounter. Most of these encounters tend to focus on evaluating skills related to history-taking, physical examinations, diagnosis, and treatment of medical conditions.
As students progress beyond these basics in their OSCEs, we might imagine examinations that mock common ethical encounters that could better prepare students for the real-life issues that they’ll confront as future doctors. Examples include consenting patients for difficult procedures, expressing disagreement about the care of a patient to team members, and reporting mistakes and/or discrimination. Incorporating these types of encounters into OSCEs would allow students to practice advocating for their own beliefs regarding these ethical dilemmas, which might have helped me when I didn’t know what to say to my surgeon preceptor. It would also reinforce to students that this type of advocacy is actually expected of them in their care of patients.
My experience and actions in the operating room contradicted my entire goal for entering medicine: to care and advocate for patients. When I entered medical training, I didn’t realize how profound the weight of hierarchical expectation would be. With our current assessment structure, the reality is that our attention is pulled toward impressing doctors and administrators instead of patients. By rethinking the evaluation structure, we can better incentivize students to stand up for who they are and what they believe in as they become advocates for their patients. We should be training future doctors to be not just excellent diagnosticians and scientists, but also patient-centered clinicians and authentic human beings willing and able to stand up for themselves and the patients they serve every day.
Chad Emerson Childers is a second-year psychiatry resident at Indiana University School of Medicine.
