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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The only reason to ask a student to do a PV exam on an unconscious
woman is to avoid having to ask consent of the woman because it would be
refused. The implication of this must be that the practice is intolerable
& probably criminal. I find it amazing that such practices could occur
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Sorry to read your statement advising us to stop doing these
unpleasant, invasive and degrading examinations.
If clinical conditions could be diagnosed by investigation, why do we need
doctors any way ? If you think PV & PR as invasive investigation, what
will a teenager say when you examine her chest ???
I feel every clinical examination is invasive, every time I request my
patient to undress, I always think of how would I feel if one ask me to do
so. This thought in me makes me be very polite and the patient feels more
comfortable and less embarrassed after the examination.
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In Box 1 of this important article it might be important to make
clear that Kant's objection was to treating people solely as means; hence
the requirement for valid consent. As other respondents have noted, many
of us will recognise a duty to assist by agreeing at times to be used as
teaching aids. The securing of our agreement is the way in which we are
also treated as ends in ourselves and therefore respected as people.
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The main reason of inventing the sthetoscope in the 1820 was not to
have better acoustic qualities, but to avoid the shocking prospect of
putting your male ear on a female patient's breast. Many doctors were
practicing obstetrical maneuvers under drapes during childbirth and were
unable to see what they were doing.In the Third Millenium, if you don't
want to upset the patient by any examination, I suggest that ultrasound or
CT scan should be carried out for any pelvic complaint.
The idea that gynecological or rectal examinations are shocking is purely
cultural. Breasts, are not considered "intimate" parts in many places in
the world.
The idea to treat breast/pelvic examination separately might induce a
confusion between sexual harassment and normal clinical practice in the
eye of the general public. This was already the case for suppositories a
few years ago.
Thus, either you ask for consent for anything done by a student, either
you don't ask for a consent at all. A student doing a breast examination
might be "psychologically disturbing", but a student with a needle or a
knife can be downright dangerous.
So far, patients are not requested to give written consent if a junior
SHO is going to operate his first appendix on them.
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I am a radiologist working in symptomatic breast work I firmly
believe that all patients should be treated with respect and that it is
simply good manners to introduce oneself and ones junior colleagues
properly to patients. Patients should always acquiesce to any intimate
exam without undue pressure. It is a great shame that we have to consider
lawyers by getting written consent so that one can be certain that good
manners are not breached.
Pressure of time militates against the proper social niceties in modern
medical practice and I believe this is what we are truely lamenting.
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The responses to this article, and to your editorial comment, reveal
an alarming gap in medical education.
Some medical medical schools have clearly not implemented the
recommedndation made in 1976 by the gynaecologist Joan Magee in the Annals
of Internal Medicine.
She suggested that at some stage in his training each male medical
student should be placed in stirrups in a bare room and a strange woman
should enter and "squeeze his balls and leave without saying a word."
It would seem that at least one of your male responders has not
undergone this educative experience
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The best way to deal with the difficult ethical issue is to stop
doing these unpleasant, invasive and degrading examinations. We do these
examinations because we have “always done them” and there importance is
overstated.
I have searched Medline looking for sensitivity and specificity of
bimanual vaginal examination in a number of conditions. This test is not
sensitive nor specific for detecting pelvic masses in clinical
practice[1]. Clinicians, therefore, should always refer for ultrasound if
you have any concerns on the basis of the clinical history. In detecting
pelvic infection vaginal examination has not been evaluated over simple
lower abdominal palpation. In patients ,therefore, presenting with lower
pelvic tenderness a high index of suspicion for infection and a low
threshold for acute referral is needed in General Practice.
Rectal examination equally is not sensitive at detecting bowel cancer
[2] especially in low risk groups like the young. Routine rectal
examinations are of questionable value in detecting early prostate cancer
and screening is of unproven benefit anyway [3]. If the history is
suggestive of pathologythere should be a low threshold for definitive
investigation irrespective of examination findings[4]
There are other options to reflect upon. Firstly, Ultrasound machines
are cheap, portable and easy to use in standard care. Perhaps we should
teach medical students how to use an ultrasound probe rather than the
stethoscope. Fortunately also these cannot be worn around the neck.
Secondarily CT has recently been shown to improve outcome in acute
abdominopelvic pain [5].
Medical myth informs much of clinical practice and has the potential
to cause much harm. Although occasionally necessary ,we need to challenge
the logic behind many of these often very demeaning examinations. Research
is needed to clarify the role of these examinations in modern medicine and
to consider the alternatives.
Des Spence
1.Is there any value in bimanual pelvic examination as a screening
test. Grover SR, Quinn MA. Med J Aust. 1995 Apr 17;162(8):408-10.
2. Clinical value of rectal digital examination in early diagnosis of
colorectal cancer (author's transl)] Weiss W, Hanak H, Huber A. Wien Klin
Wochenschr. 1977 Oct 14;89(19):654-60. German. PMID: 303021
3.Natural experiment examining impact of aggressive screening and
treatment on prostate cancer mortality in two fixed cohorts from Seattle
area and Connecticut Grace Lu-Yao, Peter C Albertsen, Janet L Stanford,
Therese A Stukel, Elizabeth S Walker-Corkery, and Michael J Barry BMJ
2002; 325: 740
4.Rectal bleeding and colorectal cancer in general practice: diagnostic
study Hans Wauters, Viviane Van Casteren, and Frank Buntinx BMJ 2000; 321:
998-999
5. Evaluation of early abdominopelvic computed tomography in patients with
acute abdominal pain of unknown cause: prospective randomised study Chaan
S Ng, Christopher J E Watson, Christopher R Palmer, Teik Choon See, Nigel
A Beharry, Barbara A Housden, J Andrew Bradley, and Adrian K Dixon BMJ
2002; 325: 1387
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Readers of Coldicott and colleagues' excellent article on the ethics
of intimate examinations by medical students may be interested in the
guidelines that we developed at the Oxford Medical School (with help from
a number of sources including Professor Campbell, Professor of Medical
Ethics at Bristol). These are intended to cover all physical examinations
of adult patients by medical students and explicitly include intimate
examinations under anaesthetic. The guidelines are available at:
http://www.medicine.ox.ac.uk/medsch/clinicalcourse/general/Chaperon.doc
We are currently developing an addendum to these guidelines to cover
the examination of patients who are children.
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This research is yet another attempt to justify '.... the political
correctness' that we are becoming obsessed with. It presupposes that
patients will be quite relaxed after having signed a form agreeing to be
examined by medical students while under an anaesthetic or in the clinics.
We appreciate that patients are anxious when visiting doctors whatever the
ailment. This paper presupposes that examination by medical students is
some kind of an assault and that by having a informed consent form signed
the patients are offered protection.
As medical students we are upset when we first witnesses any clinical
situation, be it an infant crying in the arms of a paediatrician, a young
patient being intubated by an anaesthetist or a grand old lady being
persuaded to walk by the physiotherapist.
This article is dangerous in that it isolates a vaginal or rectal
examination as being an intimate examination.
Every medial examination is intimate and soon the medical students begin
to appreciate this. Examination of the fundus of the uterus is just as
intimate for a gynaecologist as examining the fundus of the eye is to an
ophthalmologist. As a doctor one welcomes an individual to the clinic and
during the course of consultation and examination we look at the pathology
and not the person.
Medical training is all about understanding this difference. That
mole on someone's cheek is a beauty spot in a party while in clinic one is
looking at a potential melanoma.
If your researchers will care to question some ex- medical students
they will find that most respondents will confirm that they are not
overburdened by their emotions during the course of these ...'..intimate
examinations'.
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query
i wanted to know if it is legally or ethically correct for a surgeon
ot do a per vaginal examination on a 17 year old girl without her or her
guardians consent?
thank you.
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