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 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
Rapid Response:
Medical Mythology
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
Competing interests:
None declared
Competing interests: No competing interests