The ethics of intimate examinations—teaching tomorrow's doctorsCommentary: Respecting the patient's integrity is the keyCommentary: Teaching pelvic examination—putting the patient first

Dear Editor,

The ethics of intimate examinations – teaching tomorrow’s doctors

We read with interest the paper by Coldicott et al.

We see the main issues raised by the paper as these:

First, how do we ensure that tomorrow’s doctors have adequate hands on
experience to make them well trained doctors, while protecting both the
patient’s dignity and self respect and the student doctor from being sued
for assault?

Second, what is good practice and who should obtain consent for these
sensitive procedures.

And third, how far should it go?

A policy of itself is not sufficient to guarantee that a particular
procedure is followed. It needs to be reinforced with good training, which
should lead in turn to good practice. There needs to be consistent
practice throughout the country on the ethics involved with intimate
examinations and the need for written or verbal consent.

Example of good practice - at the Whittington Hospital we have been
using a student consent form for intimate examinations of women under
anaesthetic since 1997, when the Royal College of Gynaecologist’s
publication was produced (1). It is part of the student training pack.
The woman is clerked by the student, who personally obtains her written
consent to vaginal examination; only that student performs the
examination, under supervision, in theatre. Verbal consent is obtained
for examination in clinic. Examinations on mannequins, in clinics and in
theatre provide different learning experiences, all of which are
complimentary.

We are now looking to improve this specific consent form along with
our other consent forms, which have been developed in line with the
recommendations from the Department of Health (DOH) guidelines.
Why not introduce a consent form, based on this tried and tested model,
for consenting to intimate procedures under anaesthetic, for women and men
patients, in all teaching hospitals or indeed in all hospitals?

Who should obtain the consent? Verbal feedback has revealed that
students think they should. They learn the skills of creating a good
rapport, sensitivity and understanding of the patients as well as the
components of
taking a valid consent. Such a task could be tested in an OSCE – it is a
prime example of the need for good communication skills.

How far should we take this? Medical students doing rectal
examinations of the prostate, canulating a vein, palpating a breast lump
while the patient is under anaesthetic?
The DOH does not specify what should or should not have written consent,
other than implying that if risk is involved written consent is needed. It
leaves it to the Trust concerned to decide what to include. It does say
that ‘before you examine, treat or care for competent adult patients you
must obtain their consent’. So consent must always be sought by the health
professional, but the tricky question of training students with sensitive
procedures/examinations such as the above is not addressed by the DOH.
This is something that needs to be reviewed regularly within each Trust by
medical, legal and patient groups to get consensus.

Yours sincerely,

Heulwen Morgan FRCOG, Consultant/Senior Lecturer, Women’s Health,
Whittington Hospital and Sub Dean, Archway Campus, Royal Free and
University College Medical School, London.

heulwen.morgan@ucl.ac.uk

Jane Wilson RGN, MBE, Patient Information Co-ordinator, The
Whittington Hospital, London.

Jane.wilson@whittington.nhs.uk

1. Royal College of Obstetricians and Gynaecologists, Intimate
examinations: report of a working party. London: RCOG Press, 1997.

Competing interests:  
None declared

Vivienne Stern is correct in saying that in civil law, the law of
contract governs the patient doctor relationship relating to examinations
and treatment. The fact that we are having this discussion at all about
unconsented vaginal and rectal examinations, is because these procedures
are most often carried out whilst the patient is UNCONSCIOUS and therefore
they are done WITHOUT their prior knowledge and consent. Unless someone
breaks ranks in the hospital system - which is locked tight in favour of
the medical profession and therefore supportive of its practices right or
wrong, then how is the patient to find out? I doubt very much if
procedures which are done purely for the purpose of vivisection on
patients i.e. purely for pathological investigation, are going to be
written up in the patient's medical notes.

This is precisely why we need a law which states categorically that
performing examinations and treatments without consent is illegal in
CRIMINAL law and that the due penalties of bringing a case of assault and
battery against the patient would apply when the miscreant doctor is
apprehended. The law as it stands permits a patient to sue in the civil
courts if their rights are abused by doctors performing examinations or
operations on them without consent, however what it does not provide for
is any penalty at all for the person abusing the patient's rights in the
criminal courts. The doctor walks away scott free from a civil case and
the NHS picks up the compensation tab: the doctor is left with barely a
blemished record and free to do it again to another unsuspecting victim.

Please do not tell me that this is a just or ethical situation,
because I know from the experience of many that it is not, and there is
PLENTY of eveidence to show that what I am saying is correct. The reason
that wave after wave of horror stories are in the Press and Media about
the unethical practices of doctors our Health Service is because there is
no proper legal framework for Medicine in this country

Sandra Simkin

Competing interests:  
None declared

Dear Sir

You seem to have misunderstood my contribution. It was a short
response in line with a recent piece in the BMJ encouraging letters to be
as short as possible while still making the point intended. I suppose this
worked as it has generated your response. In reality I agree totally with
all the conclusions of the articles. As a general surgery SHO I did not
feel it was ethically justified for me to do vaginal examinations on
patients when we had female, senior staff who could carry out the
examination. This would surely have been better for the patient but would
have reduced the experience I got. The issue of the patients consent is a
non-issue - nothing can be done without a patients consent. What I was
taling about is the fact that, intentionally or not, changes occuring in
medicine which are to patients benefit in one way will inevitably lead to
less experience for students and junior doctors. This could have
consequences in the long term, as my original response suggested.

Competing interests:  
None declared

The article by Caldicott et al has raised very important issues. Many
of the responses, so far, seem to have compounded them.

The issues should include one about the appropriateness of
publication and why usual standards were waived in this case. The
accompanying editorial calls it ‘a triumph of academic freedom’. But, in
reality, the issue was based on (quite a good) sample of students’ opinion
in one UK medical school, that itself seems at odds with current practice
(there is no clinical experience in Year 1). Under normal circumstances
the BMJ would not have published such a study, as colleagues who have been
conducting survey research, even on important topics, in medical schools
for 20 years, ruefully confide. Perhaps the fact that it was Bristol and
that it is an obviously important issue, if generalisable to a wider
population of schools, students and staff, swayed the hanging committee.

But some of the responses beggar belief. They confirm that what has
happened to Bristol students almost certainly is happening elsewhere. And
maybe publishing the article was the quickest route to such confirmation.
Certainly quicker than funding a defensible research project. I have been
working with colleagues responsible for ethical and communication issues
in medical schools for many years and I am surprised and disappointed at
how little progress seems to have been made. We were working on these
issues in London in the mid 80’s. We had policies, at least within
Departments, and we tried to implement them. I thought, obviously
mistakenly, that in general the culture now operating recognised the
importance of, at the very least, engaging in egalitarian discussions with
patients about who should examine them and how. I thought that the culture
was also promoting the sensible procedures, or alternative or adjunct
learning strategies outlined by respondents such as written information
and consent forms, simulated and mannequin patients and so forth. I was
too complacent and that is where the problem lies I guess.

The responses
also demonstrate how restrained and polite some contributors can be. It
was really the comments made by the SHO respondent (“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”) that jolted me out of
this complacency. First because it demonstrated exactly what the patient
had said about the need for medical teachers and learners to ‘listen and
learn’. This patient was not saying that such examinations should not be
done, only that consent was needed. I hope the SHO’s boss reads these
responses, and the SHO’s boss’s boss. It seems that trying to change the
culture through broadening minds and educating future generations doesn’t
work, but changing the view at the top might. Or does Sheffield want to
move to Bristol?

Competing interests:  
None declared