The ethics of intimate examinations—teaching tomorrow's doctorsCommentary: Respecting the patient's integrity is the keyCommentary: Teaching pelvic examination—putting the patient first
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7380.97 (Published 11 January 2003) Cite this as: BMJ 2003;326:97
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Similarly to the Intimate Examination Assistants (IEA’s) program in Antwerp, the University of Queensland School of Medicine runs successful and effective teaching sessions in the second year of the 4 year graduate entry MBBS program. The Clinical Teaching Associate (CTAs) program employs women from the public to provide and assist with the teaching of the "Well Woman Check". This entails a systematic breast examination, abdominal exam, bimanual vaginal examination, and speculum examination. The session is preceeded by an extensive discussion of anatomy, instrumentation and techniques, a videotape demonstration as well as discussion with the CTAs and teaching staff from the Dept of Obstetrics and Gynaecology.
Perhaps of greatest importance is instruction on some of the specific communication skills and need to inform of the next step in the procedure. This component is about 2 hours in duration. 2 students and 2 CTAs then spend approximately 2 hours in the practical teaching session.
I believe that this process served me particularly well in the clinical years of the course. There is much to be gained from including clinical and communication aspects (which includes consent) in a single program.
Competing interests:
None declared
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Sandra Simkin's Response is absolutely correct but she is unaware
that the subject of examination of patients is already regulated by law.
For a doctor (or nurse for that matter) to examine a patient without
consent having previously been given, or having obtained a "consent"
leaving the patient under a misapprehension of the true purpose of the
examination (e.g. it is not in fact for assisting in diagnosis, but only
to allow a student to learn the technique) is the criminal offence of
assault.
Competing interests:
Patient
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Sir,
The most distressing part of this article is that we actually need to
agonize in print about whether these investigations are justified.
Whenever I need to perform an examination or test on a patient,
intimate or otherwise, I always think to myself "would I want this done to
me if I was in this patients position?". Almost always, the answer is yes.
Explaining this to the patient can help. Obviously having 20 students
lining up to examine a patient is grossly inappropriate, however this
would seem to be the fault of the overcrowding that is now endemic in our
teaching hospitals due to the overexpansion of medical schools.
Intimate examinations can be embarrasing for patients but the
embarrasment can be lessened by effective communication skills. Simply
talking to the patient like a fellow human being before any procedure you
would like to perform, explaining the pros and cons goes a long way.
The key point that features here is how we treat our medical
students. By getting seperate consent on admission we exclude them from
the healthcare team and therefore lessen the patients confidence in their
ability to carry out an intimate examination safely and with dignity. We
also retard the medical students ability to learn the value of teamwork,
something which underpins clinical practice today.
In conclusion, I believe a radical rethink of the medical students
role in clinical teams need to be rethought, with the focus being shifted
away to discrete clinical episodes towards focusing on a clearly defined
role in the healthcare team, rather than feeling like a "spare part" in
clinical situations, as is felt by the majority of medical students at
some point in their training.
Competing interests:
None declared
Competing interests: No competing interests
It has been known for many years that examinations and surgical
procedures are carried out on patients without their knowledge and
consent. The patients are are either anaesthetised at the time, and
unable to give their consent, and informed consent has not been sought in
advance. Informed consent means that the need and purpose of the procedure
or examination has been explained to the patient in such a way that it is
understood by them, and consent has been given in the full knowledge of
what will happen to them. Where procedures and examinations are suggested
entirely for the benefit of the doctor being trained, the patient should
know this and consent should be sought on that basis. That is the only
ethical contract that should be made with a patient.
Our Health Service has got into this abusive situation with regard to
patients, because hospital consultants and surgeons have not encouraged
the regulation of their activities or have actively opposed them. A group
of us feel that it is time that the work of nurses, doctors, surgeons and
consultants, was regulated in the same way that other fields of employment
in society are regulated viz. by law.
Acceptable procedures for everything from the way in which drugs are
labelled, dispensed and stored, the correct, ethical way to address
patients and and manner by which they are treated, to the precise way in
which surgical procedures should be carried out, should be laid down in
British Standards guidelines and enforceable via a new National Health
Service Act, and equivalent regulation covering private medicine. Recent
research has shown that the UK has the highest level of medical negligence
in the world. Twice as high as the USA and one third higher than in
Australia, and this we believe is the result of the lack of regulation in
our health services.
It would appear that the provisions of the Health and Safety at Work
Act 1974 are not being adhered to in the NHS either, both for workers or,
more importantly, for patients. Revelations on the dirty state of
hospitals and the poor washing of hands by doctors after examining
patients, bears this out. There are strict definitions within the Act with
regard to hygiene and facilities for workers, and to this add, patients,
which need to be observed. Additional regulations under the Act covering
medical facilities need to be added to the body of regulation, and then
facilities should be subject to independent inspection. The health and
welfare of patients should be preminent in all medical institutions and
not subjugated to the self-interested demands of medical staff.
S J Simkin
Competing interests:
None declared
Competing interests: No competing interests
At first I was going to try to explain the trauma and harm that has
been reported for many years by the patients to helplines regarding this
subject, then I realised this would probably fall on deaf ears as this
subject is not about the patients rights or views it was about how the
medical profession wish to conduct their profession.
The subject of allowing or bullying students into performing rectal
or vaginal examinations without the patients consent, sounds like a recipe
for litigation now or in the forseeable future, this is obviously
something that needs to be addressed most urgently. It would seem that
the transparency of the medical profession continues to be very cloudy.
This is how to rectify this situation, it is so very easy, here is my
suggestion.
The consultants could hand over their own rectums and/or vagina's to
their medical students once a week for a hands on experience, this may
enable medical students to hopefully stop feeling intimidated by the
consultants and give them the examination skills the consultants wish them
to have. I'm certain all consultants would be only too pleased to sign a
consent form for a weekly rectal or vaginal examination.
Competing interests:
None declared
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I recall very clearly being required to perform a vaginal examination
during the course of my final examinations in the Radcliffe Infirmary. She
was very experienced and gave me a running commentrary with clues to what
I should be finding. What is more I was required to perform it in academic
dress, without mortar board, the cape of which kept getting in the way.
Competing interests:
None declared
Competing interests: No competing interests
I read with surprise and dismay the article by Coldicott et al.
demonstrating how many students had performed intimate examinations in the
absence of proper consent. I would like to share my own experiences of
such examinations as a final-year medical school at the University of
Oxford.
I spent my preclinical years at Cambridge, and due to the nature of
the course where preclinical and clinical parts are still very separate
intimate examinations were never an issue. I note that the most of the
lack of consent occurs in the earlier years.
My only experience of vaginal examination was during the obstetrics
and gynaecology attachment, and included examinations both in both clinic
and theatre. In clinic, the outpatient nurses calling the patients in
always asked if they minded a student being present in the clinic or
seeing them first. When it came to the point of examination a doctor was
always present and they sought verbal consent from the patient to allow a
student to perform an examination.
In theatre, it was always made clear to me by staff that an
examination could only be performed if prior consent had been obtained by
a doctor and recorded on the consent form. Although doctors, particularly
new doctors, did not always remember to consent patients if they felt it
was appropriate, they were soon reminded by students as we needed to get a
certain number of vaginal examinations signed off to pass the course!
My experiences of rectal examinations have been similar. I am
pleased to report that I have never performed any intimate examination
without consent, nor would I want to. Furthermore, I am glad that I never
felt pressurised to do so by senior doctors, as some of the student
comments in Box 2 suggest. I write only of my own experience, but I would
hope that this is equally applicable to the experience of other students
in Oxford.
I note that Professor Tony Hope has already highlighted the
guidelines developed at the University of Oxford for intimate examinations
(http://www.medicine.ox.ac.uk/medsch/clinicalcourse/general/Chaperon.doc)
which were circulated to students in 2001, and are well worth reading.
Competing interests:
None declared
Competing interests: No competing interests
As an undergraduate, I think I performed about 10 vaginal
examinations, all in out-patients with verbal consent. In my pre-
registration house officer year in a very large inner city hospital I did
not need to perform any vaginal examinations and in the following year, as
a senior house officer in adult medicine in a medium sized district
general hospital, needed to perform this examination on one patient. I
then began my career in paediatrics and in the last 15 years, I have never
performed a speculum examination, and never expect to do one again.
The expansion of medical knowledge has lead to an examination of the
goals of the undergrauduate curriculum in most medical schools. It is now
clear that the medical student cannot learn or retain all, or even most of
the current body of knowledge in all specialties. The emphasis has shifted
to teaching core information and equipping students for "life long
learning."
It seems to me that there is a large group of doctors who do not need
to be able to perform vaginal examination throughout their careers. There
is a second group who need to be competent; it is unlikely they become
competent as a result of undergraduate teaching and should be trained at
postgraduate level. A third group probably perform occasional vaginal
examination; I would question whether their skills are reliable and if a
speculum examination is needed, a gynaecologist should be asked to see the
patient.
During my career I have needed to perform endotracheal intubation on
hundreds of infants, insert chest drains and umbilical catheters, yet no-
one is concerned that medical graduates have not been taught these skills
whilst students. Surely a form of examination which most patients dislike
and which is unlikely to be taught well after a few attempts should be
learned in training posts appropriate to those specialties which require
the skill.
Competing interests:
None declared
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I am a 4th year medical student and hear about the days when 17
students would line up to vaginally examine an anaesthetised woman - these
days are long gone. I agree that consent is vital and should be achieved
wherever possible and fully, or we allow poor practice and open the doors
for harm to be done. However, we must be educated, and with more and more
students this is an increasingly serious issue. I recently carried out a
PR on an anaesthetised gentleman without consent, since the surgeon wanted
me to feel his enlarged prostate; I am grateful for this experience and
feel I did no harm. In a six week block I have to gain and prove certain
skills, and finding a patient to intimately examine in a hospital
saturated with students is hard.
We had to catheterise a model in groups of four due to too few
patients and too many students. If the opportunity arises for me to do it
at the end of an operation I am observing, should I (a) turn it down as I
don’t have consent, (b) hope I do get the informed chance before I qualify
or (c) wait to do it for real unsupervised at 2am as a PRHO? I have
assisted in a hydrocoele (I held a small retractor and cut sutures), and I
gained valuable experience and did no harm – but should I have had
consent? Did I need consent to watch a gynae operation from behind the
diathermy machine? When I take a diabetic history for an assessed case
presentation I am bringing no benefit to the patient - should I be doing
it?
I agree that informed consent is important and I try to obtain it
whenever possible, but let’s not go too far. If we get to the point where
each student needs written consent to listen to a single patient’s pan-
systolic murmur radiating to the axilla, doctors will have neither the
time nor inclination to teach a ‘small’ firm of 15 students, and I’ll have
to gain my experience at 2am.
Competing interests:
I am a medical student who needs experience!
Competing interests: No competing interests
Respectful, sensitive and dignified genital exams
Dear Colleagues: In 1979, we designed a Teaching Associate (TA)
Program for Cornell Medical School which has since been introduced in most
medical schools in the USA and Canada. In this program the TA's (non-MD
women and men teachers,usually graduate students of nursing, sociology,
biology) teach medical students competent, painless, sensitive,
respectful, and communicative genital exams, first by demonstrating the
exam on each other (TA's teach in pairs) and then serving as subjects and
teaching by guidance and feedback. This program is first taught in the
second year of medical school and then repeated prior to internship.
Read
about the program in the November 1983 issue of the Journal of the
American Medical Women's Association. Prior to the TA session medical
students are required to read a small book entitled "Modern Breast and
Pelvic Examinations-A Handbook for Health Professionals" now in its 4 th
edition (1996) which can be ordered from the National Council on Women's
Health, Inc. a non-profit organization 1300 York Avenue, New York, NY
10021. Tel 212-746-6967.FAX 212-746-8691; sdb2002@mail.med.cornell.edu.
Competing interests:
None declared
Competing interests: No competing interests