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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Most patients will be only too happy to help medical students learn
by examining them. The point some doctors seem to miss is that consent is
necessary from a moral, ethical and legal standpoint. No, a patient's body
is not yours to do whatever you like with just because they have the
misfortune to end up in hospital, for WHATEVER REASON.
One wonders if some of the respondents here have even heard of the
Kennedy Report, let along read it or even the summary.
Fortunately the medical royal colleges are working with patients in
an atmosphere of equity to drive modernisation forwards. Their forward
thinking approach is closing the gap between healthcare professionals and
patients. May I respectfully suggest some doctors would benefit from
getting in touch with their Colleges and learning what is acceptable in
modern times.
Patients respect real doctors. Dinosaurs kill patient/doctor trust
and boost their own egos at the expense of the profession. Fortunately,
they seem keen to identify themselves to us.
Competing interests:
None declared
Competing interests: No competing interests
I wonder how pleased this correspondent will be when a young GP
misses a rectal cancer because he/she has never had any experience of
feeling one.
Competing interests:
None declared
Competing interests: No competing interests
Following the excellent article by Caldicott et al the Birmingham
experience may be of interest.Students are currently taught the basics of
speculum examination in their third year, during a community based
attachment known as Firm 1.They attend in a consistent group of four over
their third year.A consistent General Practitioner acts as their tutor
during this time.The group is developed with the aim of providing a stable
reflective environment for the students to learn.
The examination is taught on a one to one basis.Patients are
informed,at the time of booking a smear test, that with their permission a
student will be participating in the examination and whether that student
is male or female.
Next,they are asked to sign a written consent form on arrival at the
surgery and finally, have the opportunity to discuss any anxieties prior
to the examination with a doctor familiar to many of them.As the students
have been attached to the practice for some time it is possible they may
also be known.
We believe this way of beginning to teach pelvic examination has a
number of obvious advantages.It provides a practical demonstration of the
principle of informed consent;it offers students and patients alike a safe
and familiar environment and it supports communication and attitudinal
development as the students reflect on and practice ways of respecting
patients' dignity.We are currently exploring issues around the teaching of
intimate examinations in the community further.
Competing interests:
None declared
Competing interests: No competing interests
At a recent conference with the above title I keenly anticipated
hearing about changes implemented since the Kennedy Report, but was
disappointed to be met with the same outdated views and arrogance
displayed in most of the responses to this article. Far from being
acceptable, such unconsented examinations are equally reprehensible
whether or not the patient is awake.
Little wonder that the patient-doctor relationship has shrunk to
infinity. What other group in society would sanction behaviour - or claim
that harm to an individual is acceptable on the pretext that it is for the
benefit of a large group. Apart from contravening basic human rights,
vaginal and rectal examinations without consent abuse people when at their
most vulnerable. I speak as one who has experienced such abuse - and pain
- immediately after 4 weeks combination chem-radiation, although the
protocol allowed 6-8 weeks for the area to heal. I also suffered the years
of playback that followed.(BMJ 1998)
What of the risk of infection, tissue damage, spoiled pathological
samples? Dismissed, no doubt along with the 'hidden' psychlogical damage.
Patients' views on this well-chewed issue are well known but
ineffective it seems, for successive generations of medical students come
upon it innocently, only to have their integrity eroded as others before
them.
Such aspects of medical training must be patient-led and penalties
imposed for such abuse. For abuse it is. In any other quarter of society
what word would describe it - or those who perpetrate it?
We are well beyond 'Bristol' - but many are obviously beyond the
ability to listen or learn.
Competing interests:
None declared
Competing interests: No competing interests
Coldicott et al (2003) raise several important issues. A key point is
how students, especially in the early stages of training, can achieve
competence in procedural skills without practising on real patients.
Rather than contribute to the ethical debate, we propose that alternatives
be explored to support students in the acquisition of procedural and
examination skills.
Coldicott et al (2003) recognize that technical expertise is just one
element of competence in vaginal examination. The ability to communicate
sensitively is crucial, and indeed the patient's perspective on what is or
is not an intimate examination must be central. Practising on an
anaesthetized patient provides no opportunity to develop communication
skills but reduces vaginal examination to a purely technical task.
Moreover, simply observing a student performing a vaginal examination
provides no guarantee of what the student is palpating. Conventional
pelvic mannequins suffer from similar limitations, but pressure-sensitive
mannequins, fitted with electronic sensors, can provide feedback on which
organs are palpated and with what force (Pugh et al, 2001a 2001b).
Based on integrated teaching of other technical and communication
skills (endoscopy, suturing, urinary catherisation) (Kneebone et al,
2002), we have developed an approach that links pressure-sensitive
mannequins with simulated patients (actors), allowing students to receive
structured feedback about communication and technical skills. Students
integrate their clinical skills within a safe environment, until they have
gained both competence and confidence. This graduated approach ensures
that students are well prepared to deal with the contextual challenges
they may face when dealing with real patients in real settings.
Clinical teaching associates (women who volunteer to undergo vaginal or
rectal examination, and who are trained to provide feedback to students
about both technical and communication skills) are established in medical
schools in other parts of the world and there seems scope for such methods
in the UK.
Including such approaches within curricula may help to avoid unacceptable
situations such as those described by Coldicott et al.
References
Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations -
teaching tomorrow's doctors. BMJ 2003;326:97-101 (11 January)
Kneebone RL, Kidd J, Nestel D, Asvall S, Paraskeva P, Darzi A. An
innovative model for teaching and learning clinical procedures. Medical
Education. July, 2002;36;7: 628-634.
Pugh CM, Heinrichs WL, Dev P, Srivastava S, Krummel TM. Use of a
mechanical simulator to assess pelvic examination skills. JAMA. 2001 (a)
Sep 5;286(9):1021-3.
Pugh CM, Srivastava S, Shavelson R, et al. The effect of simulator
use on learning and self-assessment: the case of Stanford University's E-
Pelvis simulator. Stud Health Technol Inform. 2001 (b);81:396-400
Competing interests:
None declared
Competing interests: No competing interests
Sir
In the early 70's 'World Medicine' (of blessed memory) published a
letter from me in which I expressed my puzzlement at the variety of
apparent sentiment amongst women on the subject of vaginal examination. I
am not much less puzzled now. Perhaps if I had one, I would understand
better.
Like many male medical students I am sure that I owe a far greater
debt of gratitude to my wife than to any teacher.
The nearest I am ever likley to come, however, is a rectal
examination and with the strangury advancing I am conscious that my
appointment with the fickle finger of fate cannot be very far off. Am I
concerned? Not in the slightest. Short of appreciable discomfort I would
not hesitate to contribute to the education of as many students as were
interested but then, to me, it is a trivial and comprehensible procedure
having no more consequence than, say, abdominal examination.
The morbidly delicate metropolitan sensitivities that inform so much
debate in the ethical area are running amok in the practice of medicine
and threaten to so mire it that ere long it will become frozen by
regulation and diktat.
The majority of women convey to me the impression of impassive
neutrality about vaginal examination, only rarely is there a noticeable
apprehension. Terror and enthusiasm are both extraordinarily rare.
Are we quite sure that the majority of women are not perfectly
sensible thoughful creatures who are quite capable of expressing
themselves, when conscious at least? Examination under anaesthetic without
valid consent ought to be consigned to history but then I have always
thought it an effete teaching exercise on practical grounds - let alone
ethical ones.
Emphasising the routine, stigma-free, health affirming nature of
examination (of any part) to the public at large and educating them about
the nature and purpose of examination could be so valuable. Channel 4 -
are you listening - I am free for a screen test any time...
We urgently need a vigourous reassertion of the utilitarian ethos.
The BMJ should always include a balancing view when the distinction is
drawn between two opposing camps.
Yours, with a nervously pouting sphincter
Steven Ford
Competing interests:
None declared
Competing interests: No competing interests
I can remember intimate examinations by medical students being an
issue in educational circles over 12 years ago. The concept of students
queuing up to examine a patient under anaesthetic was exposed and deemed
to be unacceptable at that time and must remain uncacceptable now.
I find it difficult to accept that any student is asked to examine a
patient under anaesthetic without specific consent being obtained first.
In the 9+ years I have been a consultant gunaecologist it has normally
been the responsibility of the student to request permission to examine a
patient under anaesthetic - and to obtain signed consent. Without the
consent being signed as a separate event the student does not examine the
patient.
This acts to protect the patient from unwanted examination, and
forces the student to talk to the patient. I believe that both of these
benefits are important. I hope that this is the usual practice in most
hospitals
Competing interests:
None declared
Competing interests: No competing interests
We would first of all like to congratulate the authors, especially
Yvette Caldicott for having the courage to raise the very important issue
of consent to intimate examination. The article certainly generated a
significant amount if debate within our household.
As a medical student in the late 70's I was exposed to similar
encouragement to examine women under anaesthetic without any prior
knowledge of consent given. I have memories of feeling uncomfortable about
not just performing an intimate examination under the gaze of my
consultant but also by the fact that I was unable to obtain consent from
the patient. At the same time, my wife, who was in a different part of the
country observed similar practices whilst training as a nurse
The effect on my wife was more profound. She felt that this was a
gross abuse of the patient, but on expressing her feelings the response
was "she's asleep and would never know, don't go making trouble". This
frustrated her attempts to protect the patient and created a mistrust of
the medical profession which persists to this day.
This had significant consequences for her when she was faced with the
prospect of having to have a nephrectomy. Only after lengthy negotiation
and the support of a good friend (a theatre manager) who agreed to act as
an advocate did she feel confident enough to consent to nephrectomy.
It should be recognised that, not only is it of overwhelming
relevance to the patient, but is important to the staff who have direct
responsibility for the care of the patients. Similarly for the students,
who are not only learning their skills but developing attitudes towards
patients.
On this latter point I would like to note that my daughter has
expressed an intent to study medicine, she was encouraged by the fact that
medical students had expressed concerns for the patient and a desire to
maintain high ethical standards. She felt that with these attitudes,
perhaps there was hope that there would be a good chance that there would
be improvements in the future.
With the raised profile of medical ethics, the shift away from
compliance towards concordance and the debate around consent generated by
the Alder Hey investigation, we too felt that there would have been
changes from our experiences in the 70's. Sadly this has proven not to be
the case. Perhaps the only answer is to involve the public, the population
we are meant to serve, in the debate.
Competing interests:
None declared
Competing interests: No competing interests
As a clinical medical student, I read Coldicott et al's paper with
great interest. I can relate to those students who felt uneasy about
carrying out examinations in certain situations and the difficulties of
knowing how to refuse involvement when this occurs.
With time, I have grown in confidence and now feel more able to stand
up for what I believe in order to ensure best patient care. However, I
wish I had felt more able to do this from the start, and feel it is
imperative to keep in mind the reason we are here - training to become
doctors, to do the best for our patients.
Applying the utilitarian argument to justify student examinations
which may in some way be harmful to patients does not hold completely
true. In this situation, students may well learn the technicalities of
physical examination, but will fail to acquire other skills vital to being
a good
practitioner - those of empathy and humanity to name but two. If the
practice of students and staff is evaluated and improved now, both ethical
teaching and improved patient care will result.
When I am a doctor, I hope (as I'm sure do most doctors) that any
students I teach will be able to form ethically-considered judgements and
act in the best interests of their patients. However, I also hope that
they will have the confidence to follow their judgements through in
practice. In this way they will truly be acting as doctors-to-be, and
demonstrating skills equally important as competence in clinical
examination.
Competing interests:
None declared
Competing interests: No competing interests
Intimate examinations on volunteers during medical school: a challenge at the University of Antwerp,
Coldicott et al. highlights concerns regarding the use of patients in
training clinical skills. Our current program for training fifth-year’s
undergraduates could serve as a model for dealing with these legitimate
problems. Our aim was to create a “safe” environment to learn intimate
examinations. The project was approved by our ethical committee.
Twenty healthy volunteers were recruited as Intimate Examination
Assistants (IEA’s) and were screened for their characteristics and
motivation. Each IEA signed informed consent. They received an
introduction in anatomy, technical examinations, doctor-patient
interactions and feedback training: in our setting the IEA served both as
patient and as teacher. Medical staff was trained in supervising and
coordinating the feedback sessions. Before, students were informed on the
scenario, and technical skills were teached on manikins. A comprehensive
training manual was produced.
Students performed three training sessions (urogenital-rectal,
gynaecological, breast examination) Each setting consisted of two students
(performer – observer), one IEA and one medical doctor. The students,
IEA’s and supervisor had sufficient opportunity for feedback to
contribute and ventilate their feelings and concerns. The attention was
mainly focused on personal attitude, technical and communication skills of
the students.
The program was evaluated at 3 levels (students, IEA, supervising
staff) by structured questionnaires, personal reflections of the students
and round-table conferences. Preliminary data showed a positive
appreciation of the training by students and IEA’s. Both stated that the
feedback moment was of utmost importance for the mutual understanding and
appreciation. The students were grateful to work with IEA’s.
Trust and respect were positive outcomes of our setting of combined
training of technical and communication skills. As the students reported
themselves: “It will certainly help us in our future careers, we feel more
secure while performing intimate examinations, and having more attention
for the patients, their feelings, integrity and privacy.”
K. Hendrickx[1], B.Y. De Winter[1], J.J. Wyndaele[2], F. Mast[1], B. Selleslags[1], L.Debaene[1], W.A.A. Tjalma[3], Ph. Buytaert[3], L. Bossaert[1]
[1]Skillslab, [2] Dep. of Urology and [3] Dep. of Gynaecology, University of Antwerp, Belgium
Coldicott Y. et al The ethics of intimate examinations – teaching
tomorrow’s doctors. BMJ 2003;326:97-101 (11 January)
Competing interests:
None declared
Competing interests: No competing interests