Education vs Patient Satisfaction and Patient Safety

One of the students working with me on L&D recently complained that she wasn’t getting to do enough cervical exams. She felt that she should be personally checking her patient’s cervix every two hours. Now, for patients undergoing cervical ripening or in early labor, I don’t check every 2 hours – I space exams about 4-6 hours apart, depending on how the patient is feeling.

Our department’s policy is that students can do cervical exams if the patient has an epidural and membranes are intact. The thought is that if cervical exams are painful for the patient, it is unfair to subject the patient to an unneccessary additional exam. Students who are planning to go into peds or neurology don’t actually need to be able to measure cervical diation and effacement, so it seems unreasonable to subject a patient to a painful exam with little educational benefit. When membranes are ruptured, additional checks increase the risk of chorioamnionitis, and it seems unreasonable to increase the patient’s risk of a serious infection for the student to practice a skill that he or she will never use outside of medical school. We see cervical exams as a specific clinical skill different from the “general medical skills” required by all physicians: performing an abdominal exam, heart and lung exams, basic otoscopy, etc. On the other hand, we make more of an effort to allow the off-service (emergency medicine and family medicine) residents to check patients, because they need to develop that clinical skill in order to treat their future patients.

I also had a student complain that she wasn’t getting enough deliveries on her rotation. The deliveries we had had during her rotation up to that point:

• A patient who we were very concerned was going to have a shoulder dystocia (macrosomic baby, pushing poorly, first delivery)
• A 34-week premie, patient with preE with severe features, on magnesium
• A patient who rolled into triage and had her baby 10 minutes later, screaming and climbing up the bed

We also had a family medicine resident on-service who needed to get deliveries in order to graduate from his residency, so I was trying to split the patients between the student and the off-service resident. The student wanted to go into pediatrics. I firmly believe that every doctor should deliver a baby in medical school, but what do you do when forced to decide between giving the delivery to a student as part of their general medical education, and giving it to a family practice resident who is going to be caring for laboring patients independently after only 30 deliveries, possibly without an obstetrician available for backup?

What do you think? When is it appropriate for students to do cervical exams? How do you explain to students why they can’t always check the patient’s cervix? Is is appropriate to have different rules for off-service residents than for medical students? How do you decide which students or off-service residents to assign to follow which patients?