MEDICAL MATTERS:Medical students need to learn how to carry out thorough but speedy examinations of real body systems
DID YOU ever stop to think how doctors and other healthcare professionals learn to do intimate examinations? I’m thinking of vaginal and breast examinations in women, rectal examination in both sexes, and testicular examination in men.
In order to be properly trained and competent, these skills must be learned correctly, but it is asking a lot of a patient to agree to additional probing just for the benefit of a fumbling student.
Modern technology means that mannequins are now quite accurate anatomically, but there is more to examining a person than mechanically checking for abnormalities.
Unlike commercial pilots, who now learn to fly in simulators and only handle the “real thing” on their first passenger flight, doctors need to spend many hours learning to carry out thorough but speedy examinations of real body systems.
Examining someone’s heart or lungs is easier for most students and patients than having to undergo an intimate examination.
Consent must still be sought, but it is sufficient to do this verbally in the majority of cases. Ethics has moved on since my time as a medical student and learning to carry out a pelvic examination in a woman must occur only after full written consent.
There is a tradition of these skills being taught on women who are having a general anaesthetic, which makes sense in terms of lessening the trauma for the patient.
However, as Royal College of Obstetrics and Gynaecologists guidelines state: “In cases where pelvic examination under general anaesthesia is regarded as being of educational value, written consent must be obtained from the woman before she comes to the operating theatre.”
But is this actually happening in the Republic?
A short paper in the current issue of the Irish Medical Journalsuggests it may not be. Doctors at the Department of Obstetrics and Gynaecology in University Hospital Galway looked at the case notes of some 222 women admitted to the hospital for elective gynaecological procedures.
It is unit policy that a simple written consent form, asking permission for one medical student to perform an examination while the woman is asleep, is given to the patient along with the standard consent form for the operation itself.
Just over a quarter of women specifically refused permission for an intimate examination by a student in theatre. Private patients were less likely to give consent than public patients. In addition, women who had babies in the past were more inclined to say yes.
A worrying finding, however, is that in 46 of the 222 charts, there was no student consent form in the chart or the consent form was blank. While we cannot be certain, this suggests a significant minority of women were not properly consented by the admitting doctor.
It also raises a question as to whether any of these women were intimately examined by a medical student, perhaps in the belief the patient had, in fact, consented.
The researchers also surveyed the 29 gynaecology units in the country that teach medical students. Just five of these units have a dedicated written consent process for students to undertake pelvic examinations under anaesthesia.
This is an alarming finding which suggests the majority of Irish women undergoing gynaecological procedures are at risk of being examined by a medical student while asleep on an operating table, without their explicit consent. Even for one woman to be examined without her knowledge or agreement is unacceptable.
According to the authors, “In the past, the teaching of pelvic examinations under anaesthesia has been done without the explicit knowledge of the patient . . . Medical educators presumably rationalised this by the fact that it is an essential skill to learn and no physical harm comes to the patient. However, this attitude does not meet current ethical standards”.
And they make the important point that if proper ethical procedure for obtaining full informed consent is not shown to be used in everyday practice, then there will be a decline in students’ attitudes towards consent as a vital element of patient care.
Drs Martyn and O’Connor are to be congratulated on carrying out and publishing this research. It is now up to medical schools and the Medical Council to ensure the issue of medical student consent for intimate examination is placed at the top of their agenda for remedial action.
In the meantime, every woman who undergoes an anaesthetic for a gynaecology procedure would be advised to raise the issue of consent with her admitting doctor.
- mhouston@irishtimes.com