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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Whenever I visit my breast clinic for the annual examination, the
doctors no longer introduce themselves. I have to look at their badge to
see who they are and what they do.
I don't mind being the ductal carcinoma in room 3. I don't mind
sitting in a cold room wearing only a thin gown for ten minutes while
waiting to be seen. But I would like to know who is going to touch my
breasts and whether I'm dealing with a SHO or senior registrar.
After two such experiences, I mentioned this admittedly trivial issue
to the consultant in charge and to the attending nurse. Alas, it was
business as usual when I returned the next year.
What on earth is so wrong with a simple greeting? 'Hello. I am doctor
John Caring. I am Mr Friendly's registrar.'
Why should it be up to me to find out who is going to examine me? Is
it all part of some cost cutting exercise? Or am I what some refer to as
'demanding'?
I'm due to attend the clinic again this week. I shall take my reading
glasses with me. And think of the good old days. When they shook my hand,
introduced themselves, and sometimes even offered me a reassuring smile.
Competing interests:
None declared
Competing interests: No competing interests
As someone who regularly carries out breast, vaginal and rectal
examinations on patients I found myself irritated by both the paper and
editorial about ‘intimate examinations’, which seem to make ethical
mountains out of everyday molehills. I only hope the paper does NOT
generate ‘wide media interest and …calls for a public inquiry’.
Of course, students experience feelings of awkwardness when first
performing internal examinations, as do patients when undergoing them. But
students worrying about Kantian ethics (or indeed the principles of
utilitarianism) will not make the experience any more relaxing for either
party. For doctors, a vaginal examination should be no more of an ethical
issue or an intimate moment than listening to a chest, or palpating an
abdomen. And if we can get that attitude across to patients, they too will
feel much less embarrassed and awkward.
The gynaecology consultant urging medical students to examine a
patient while under anaesthetic, with or without consent, is not some sort
of serial pervert. Most likely he has carried out so many of these
examinations himself that it is simply no longer an issue. After all,
compared to a D&C or a vaginal hysterectomy, internal examinations do
not seem particularly traumatic. And he knows that the more practice
students have, the more relaxed and more competent they will be when it
comes to their own future practice.
What is important for us as medical professionals is first and
foremost to ensure we have adequately treated our patients’ medical
conditions, which means we have to be able to examine them thoroughly.
This is the true basis of a trusting doctor-patient relationship.
Competing interests:
None declared
Competing interests: No competing interests
Coldicott’s study1 and the accompanying
debate highlight an important inconsistency between what we know to be right and
what happens in practice. It was interesting that both commentaries were written
by gynaecologists, particularly considering it was rectal examinations on which
only one responding medical school had a formal policy. Unfortunately, the study
did not differentiate between consent obtained for gynaecological and surgical
examinations. One is left wondering what the surgeons make of all this.
The challenge of obtaining consent for students undertaking pelvic examinations
both in clinic and under anaesthesia is acknowledged and here may lie the reason
for the failure to obtain appropriate, informed consent. A recent study confirms
our perception that this is more often a problem for male students.2
Older and parous patients are identified as those more likely to agree, and the
authors suggest these women be specifically targeted for involvement in medical
education.
Other research, 3 reports that the main reason
women agree to medical student involvement is a desire to contribute to the training
of future doctors. Rapport with the student was cited in one third of cases to
be important and an anxiety about privacy was the most common concern in those
who declined. In this study, 84% of patients overall were happy for students to
be involved in the consultation and 68% for this to include intimate examination.
It is understandable that if we give the student’s presence no context then
it may be seen only as an uncomfortable addition to an already embarrassing event.
Student rapport is crucial and in the outpatient setting this is usefully achieved
by allowing the student to clerk the patient beforehand; a skill they obviously
need to develop in any case.
Finally, when obtaining consent, doctors should perhaps take an early opportunity
to reassure about issues of confidentiality, given that this may be a pivotal
issue for some patients.
1. Coldicott Y, Pope C & Roberts C. The ethics of intimate examinations -
teaching tomorrow's doctors. BMJ 2003;326:97-101 [Medline].
2. Rymer J & O’Flynn N. Women’s attitudes to the sex of medical
students in a gynaecology clinic: cross sectional survey. BMJ 2002; 325:
683-4 [Medline].
3. Ching SL, Gates EA, Robertson PA. Factors influencing obstetric and gynecologic
patients’ decisions toward medical student involvement in the outpatient
setting. Am J Obstet Gynecol. 2000; 182: 1429-32.
Competing interests:
None declared
Competing interests: No competing interests
Valid consent is required to perform any examination. That is common
courtesy, basic respect for the person, is the law and that is what must
be done.
As a patient, however, about to be examined by a health professional
trained with the co-operation and consent of previous patients, surely it
would be unethical of me to refuse a request to be examined by a student?
Competing interests:
None declared
Competing interests: No competing interests
The article on ethics of intimate examinations was
revealing of many things. In particular it demonstrated
that there is a spectrum of thought on the matter.
However, doctors are at risk of losing a grasp of
common sense and their duty to learn for the benefit of
all if they try to lead in the field of political correctness. If
a student is participating in a procedure as part of the
clinical team they must expect to be covered by the
consent process entailed in the procedure. Whether
they are examining in the mouth, the perineum or the
armpit should make no difference. It is wholly
appropriate to respect the sensitivities of the patient
when awake and decorum and ones own sensitivities
when they are asleep. However, students should not be
considered outside the clinical process. They often find
things busy clinicians don't notice.
Competing interests:
None declared
Competing interests: No competing interests
I would like to add a comment to this excellent
discussion. It is a personal experience, and it dates
back over 20 years, so I hope that what happened to
me then would not happen now. Nevertheless, the
discussions of BMJ 11 Jan hinge around the subject of
consent, and that is what my experience addresses.
I was 20 years old and awaiting surgery at
Addenbrookes hospital for a large, lifelong hiatus
hernia which was causing SVTs. It was about two
weeks before clinical school finals, but I was a first year
preclinical student and knew nothing of hospital culture.
I was admitted two days before my surgery for
monitoring. During that time I lost count of the number
of ‘doctors’ who interviewed me but it was between
twelve and twenty. All performed vaginal or rectal
examination. Three or four performed both, which I
found particularly distressing. Consent was obtained in
the form of ‘now I need to…, if you don’t mind’, and I
implied consent by my physical position and a muttered
and embarrassed ‘okay.’ Apart from chest and
abomdinal exams, which all did, three students also
performed breast examination, although none
performed ENT examination.
I was upset by th examinations and felt both vulnerable
and unclean after them. The fact that my memories are
vivid twenty years on tells its own story. I agree that I
gave a sort of consent. It was pretty informed too – if not
the first time, certainly by the twelfth. Nevertheless it did
not cross my mind for one second that I was in a
position to refuse. One can ask 'do you mind' wqithout
really making the patient feel they are honesty being
given a clear run at saying 'no'. After the first three I did
not want to be examined any more, but i did ot believe i
had a real choice, I thought i was being asked only out
of politeness.
Looking back I needed an advocate, someone who
was not a doctor to make a rule, to say, none of these
patients should be examined by more than two of you
students, and before you do it I’m going to make quite
sure she knows how to say no. Because without one,
for a patient, the sense of vulnerability and aloneness
can be enormous.
There was one other issue. I did not really know they
were medical students, I thought they were all doctors.
They may have said otherwise, but I was unaware of
how medical students worked in hospitals – in
Cambridge the preclinical and clinical courses were
entirely separate at that time. I did not expect
unsupervised students to be examining patients, and
what people don't expect to see, they often don't see.
I believe it provides a good illustration of how
meaningless consent, even explicit informed consent
is, if the patient is not fully aware of the set up and does
not, crucially, have an advocate on the ward.
Competing interests:
None declared
Competing interests: No competing interests
Informed consent has to be regarded as a “sine qua non” condition in
teaching our students. On the ward it is relatively easy to obtain consent
from the patients a teacher likes to present to the students or trainees.
The patients admitted to the ward were seen by the staff long before they
became an interesting subject (object) of a learning process and the
teacher had time enough to speak to the patient in privacy about his/her
exposure to the persons not involved in the care process.
In ambulatory circumstances we are faced with a flow of numerous
patients during the session and interesting learning points can be missed,
if we try to involve students only after the consultations. There is no
other way than putting the students aside the doctor or practice nurse in
the examination room. Consultation process is an intimate one in any case,
with some extraordinary situation which cross the border of personal
integrity of a patient, i.e. any physical examination or disclosure mental
problems. When the patient is in the office it is often to late to give
the patient the possibility to decide on the presence of the student
without prior notice. Sometimes patients feel embarrassment and they are
afraid to loose doctors attention when opposing compliance with suggested
procedures and students involvement, if asked late in the consulation or
even never asked.
Family practice does not poses such high frequency of examination of
intimate parts of human body as gynaecology but at our department we
decided to produce an information leaflet to the patients visiting GP’s
office in which a student participates in the learning process. Each
leaflet explains the fact, that there is a student in the office and that
the patients are kindly asked to allow participation of the student in the
consultation and offer the patient the option to ask, that the student is
not present during the whole or during part of the consultation. They can
ask for that at the reception desk or the doctor him/herself. The leaflet
is uniformly designed, issued in each indivdual case by the Department of
Family Medicine, labelled by the name of the student and the practising GP
- trainer and signed by the head of the department. Trainers are also
instructed to seek consent about performing any physical examination,
especially rectal and pelvic or performing any other procedures i.e.
injections, suturing, incisions etc. by the student.
So far our experiences are good. Trainers are reporting high
participation of patients and very good response from those, who were able
to ask the student was not present on exceptional occasions.
We believe written information to the patient beforehand is the first
step, which can help in getting informed consent from the patients in
students participation during medical care.
Competing interests:
None declared
Competing interests: No competing interests
What next ?
Over the years, I have learnt a great deal and changed my method of
medical practice based on research and publications. I never thought a day
would come when we need consent for every thing. Why was this study
conducted? Does it in any way help us to manage patients better or does
this study prevent any harm inflicted on a patient?
I feel there should be strict guideline to prevent and publish
studies that could harm patient care in the long term. I do not feel
comfortable to be examined by a partially trained doctor. Medical students
training should include rectal or vaginal examination if indicated. This
is part of routine care and must be covered by informed consent.
Patients are aware of training doctors in hospitals and rarely object
physical examinations. Some patients are keen to oblige, so why make an
issue of this so-called "intimate examination". I dread to see a day when
I will need a special consent to examine the chest of a woman and a lady
doctor requiring one to examine the genitalia in a male patient.
Competing interests:
None declared
Competing interests: No competing interests