Wednesday, 26 January 2011

Intimate examinations without consent- it's still happening.

exam room
Image: Exam Room by Maggie Osterburg

Having an intimate examination can be uncomfortable enough, but the thought that a medical student might be examining you without your clear consent is hard to accept in 2011.Although Canada only introduced guidance that explicit consent from patients was needed for pelvic examinations  less than six months ago (and following much dissent in the press), in the UK and Australia this has been established policy for many years. But researchers from Cardiff and Dundee universities who were exploring UK and Australian  medical students 'professionalism dilemmas' found that the students often told stories of performing intimate examinations without consent. Sometimes they challenged being asked to perform an examination by a doctor-tutor, but more often the stories were of going along with requests despite knowing it was against their school's policy.
The researchers conclude that having a policy is not enough to change the behaviour of doctors who request students to practice examinations of patients without consent despite clear guidance which says this is wrong.
So where next? To try and quantify how common some of the professionalism dilemmas such as this are, the researchers are now carrying out a survey of all medical students in the UK which can be found here, and have set up a Facebook group to support the research. They also hope to study why the policies have not had the impact on doctor-tutors that would be expected.

Press Release from University of Dundee.

EDIT: Annabel Bentley has suggested that action needs to be taken. What do you think?

Rees CE, & Monrouxe LV (2011). Medical students learning intimate examinations without valid consent: a multicentre study. Medical education PMID: 21251051

ResearchBlogging.orgYou can see some of the discussion about this on twitter via @storify here

Edit 7/2/2013: This paper got a lot of press coverage especially in Australia. Here the authors, Lynn and Charlotte, respond to the media coverage of their research. There were shocked at the reaction and decided not to engage in the media storm. Right decision?


  1. Annabel has also been trying to post another comment:
    "What can we conclude? That having a policy does not magically change all practice? I think it would be magic if any policy was 100% effective in terms of behaviour change. Is there any research on what other levers would help to choose behaviour faster?"

  2. Annabel,
    Thanks for trying to comment! The research is actually very detailed in its analysis of students' explanations for why this happens. The authors (and of them is my colleague @LynnMonrouxe) suggest that the main influence on students is what they describe as a "weak ethical climate". I'm going to copy their suggestions:

    "These findings have numerous implications for developing an appropriate (i.e. strong) ethical climate. We know from our findings that policy alone is insufficient to prevent ethical breaches involving intimate examinations in workplace learning. Policy developers must therefore ensure that all clinical teachers with responsibilities for helping students learn intimate examinations know what the policy is and put that policy into practice. This protocol must be supported through the provision of structured faculty development workshops to allow for dialogue about policy strengths and challenges and possible threats to implementation.

    Medical students should also be provided with structured opportunities to learn about the ethics of intimate examinations with patients, along with the psychosocial factors that might impact on their compliance and refusal behaviours. Thus, students should be introduced to the school’s policy on intimate examination well before they enter the clinical workplace. (Some of our students found themselves in dilemmas relating to intimate examination long before such learning was expected by the school.) Students should also be introduced to the social psychology literature on issues of obedience and conformity. We believe that if students are aware of the social influences on their behaviour – including the forces of legitimate individual and institutional authority and the need to conform with the behaviour of peers – they will be better prepared to work against such influences. Thereafter, students should be provided with regular small-group tutorials that offer a safe and open forum in which they can discuss their intimate examination dilemmas. Such sessions should help students to make sense of their dilemmas, obtain support, recommit to their values and formulate strategies for dealing with future dilemmas relating to intimate examinations."

    Your suggestion to have a campaign to raise awareness of this issue may be a good move. There has been a lot of discussion about this recently in Canada so I wonder how that has infuenced behaviour there.

  3. Rational policy is great, but it doesn't always lead to action. Perhaps we need to stimulate the battle for hearts & minds? Hence my suggestion on Twitter to start a campaign.

    The other challenge is the battle for attention... why is this issue worth attention, compared to other public and global health issues?

    The results of your research to quantify the issue will be really useful.

    What does anyone else think?

  4. I think it is an issue because it shows a fundamental respect for the person who should be cared for. If we tolerate this then we might not have much hope of having meaningful debates on other areas of injustice in global and public health. That's what I think!

  5. Unfortunately, this does not reflect well on colleagues in O+Gand their attitudes towards their patients, medical students or ethics. I would suggest the students are already placed in a difficult situation by someone suggesting the exam; it is the attitude of the "tutor"that requires change. This will bea challenge as it clearly continues to be "acceptable practice"in their eyes.

  6. This issue came up at a dinner party with medical students recently. I also forwarded the abstract to Chris.

    We discussed the issue when he came home. The students especially the female ones had expressed their disgust that such examinations were occurring but they felt that if they refused they risked "being failed or ridiculed" by consultants.

    As Chris pointed out if a woman enters a night club and is given a sedative and is then taken advantage of the man is charged with indecent assault or rape. He doesn't see that there is actually a difference and that medical staff are committing a crime.

    I feel nauseous about the subject no only as a midwife who believes passionately about informed consent but also as a woman if I ever discovered that this had happened to me I would take it to the highest courts in the land and the only justice I would be content with would be jail.

  7. Thanks Pam and @ffoliet,
    The sooner that the culture changes throughout medicine, so that there is no doubt in anyone's mind that this is unacceptable, the better.


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