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The ethics of intimate examinations: teaching tomorrow's doctors
These are some of the many responses to the paper saying medical students may not get consent for examination under anaesthetic. You can read the full paper and the rest of the responses at http://bmj.com/cgi/content/full/326/7380/97
Students need experience
I am a fourth year medical student and have heard about the days when 17 students would line up to examine the vagina of an anaesthetised woman; those days are long gone. Full consent is vital and should be gained wherever possible, or we allow poor practice.
We must be educated, however, and with more and more students this is increasingly difficult. I recently carried out a rectal examination on an anaesthetised man without consent, since the surgeon wanted me to feel his enlarged prostate; I am grateful for this experience and feel I did no harm. In six weeks I have to acquire certain skills, and finding a patient to intimately examine in a hospital saturated with students is hard.
We had to catheterise a model in groups of four owing to too few patients and too many students. If the opportunity arises for me to do an examination at the end of an operation I am observing, should I (a) turn it down as I don't have consent, (b) hope I do get the informed chance before I qualify, or (c) wait to do it for real unsupervised at 2 am as a preregistration house officer?
I have assisted in a hydrocoele (I held a small retractor and cut sutures); I gained valuable experience and did no harm, but should I have had consent? Did I need consent to watch a gynaecological operation from behind the diathermy machine? When I take a history from a diabetic patient for an assessed case presentation I am bringing no benefit to the patient; should I be doing it?
Informed consent is important, and I try to obtain it whenever possible, but let's not go too far. If we get to the point where each student needs written consent to listen to a single patient's pansystolic murmur radiating to the axilla, doctors will have neither the time nor inclination to teach a "small" firm of 15 students, and I'll have to gain my experience at 2 am.
Aneel A Bhangu fourth year medical student, Birmingham Medical School
Email: aneelbhangu@yahoo.co.uk
No excuse
I read with interest the article on consenting patients for examination, especially the fact that many students did not know whether consent had been obtained or not. It is now more than a year since I did my obstetrics and gynaecology attachment, but I remember well the embarrassment I felt on having to obtain consent, never mind the patient's embarrassment and anxiety. As a student I was expected to try and obtain consent from every patient that went into theatre. Although many people would say I was overzealous, I would never examine a woman unless I had got their written consent in their notes first.
What surprised me was the senior doctors' reactions to my actions--even in the current climate of litigation, they felt it unnecessary to go so far as to get written consent. I, on the other hand, preferred not to take the risk of a patient changing their mind afterwards and myself then having no evidence to cover my back.
Students need to take responsibility for gaining consent, especially as many experienced senior doctors are still behind the times with regards to modern practice. At the least, it is naive for a student to expect consent to have already been sought and at the most plain stupid. Also, students should never feel pressured into having to examine the patient, just because a consultant is intimidating, especially if they have no idea as to the patient's wishes.
Patients are our only resource for gaining proper experience of clinical practice--they should not be abused. You should always get consent for anything you do, and for the more intimate consultations, written consent should be a necessity. Senior doctors should also be brought up to speed on modern practice, as it is no longer acceptable to assume that the patient will not mind, or to pressure a student into doing something unethical.
Ed Bayley fifth year medical student, University of Nottingham
Email: mzysejb1@nottingham.ac.uk
Ethical mountains out of everyday molehills
As someone who regularly carries out breast, vaginal, and rectal examinations on patients, I found myself irritated by both the paper and the editorial about intimate examinations, which seem to make ethical mountains out of everyday molehills.
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.
A gynaecology consultant urging medical students to examine a patient who is under anaesthetic, with or without consent, is not some sort of serial pervert. Most likely he or she has carried out so many of these examinations himself that it is no longer an issue. After all, compared to a dilatation and curettage or a vaginal hysterectomy, internal examinations are not particularly traumatic. And consultants know 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.
Elizabeth H Frayn senior house officer in general surgery, West Cornwall Hospital, Penzance
Email: efrayn@fsmail.net
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