The ethics of intimate examinations – teaching tomorrow’s doctors
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Education And Debate
The ethics of intimate examinations—teaching tomorrow's doctorsCommentary: Respecting the patient's integrity is the keyCommentary: Teaching pelvic examination—putting the patient first
The ethics of intimate examinations – teaching tomorrow’s doctors
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.
Rapid Response:
The ethics of intimate examinations – teaching tomorrow’s doctors
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
Competing interests: No competing interests