We read with interest Broadmore et al.’s1 recent article on medical students’ experiences of vaginal examinations of anaesthetized women. This remains one of the pillars of teaching vaginal examinations to medical students. A fact borne out by their students’ responses, where all but one felt that is was of educational value. We were surprised, however, that 17 of 114 women were examined under anaesthetic without giving written consent. The Royal College of Obstetricians and Gynecologists guidelines2 on intimate examinations published as long ago as 1997 states ‘in cases where pelvic examination under general anaesthesia is regarded as being of educational value, written consent must be obtained from a woman before she comes to the operating theatre’.
Our experience is similar to that of the University of Otago in so far as it is often difficult for medical students to approach the patient to gain written consent. With this in mind, an improved policy of obtaining written consent was developed in our unit. The admitting senior house officer explains to the woman that she is consenting to one medical student performing an examination before her procedure. They explain that this will help in the student’s education. If she agrees, the specific consent form is signed as well as a standard hospital consent form for her operation. We recently audited 222 consecutive admissions and found that 26% of women actually refuse permission for such an examination to be undertaken.
The teaching of intimate examinations poses ethical problems for students and educators; students must learn but patients must be protected. A significant number of women when asked will refuse permission. One quarter of women in our study specifically refused consent despite careful counselling. Their wishes must be respected. All units where medical students’ teaching is undertaken should have a specific policy for obtaining informed written consent in these circumstances. While it can be argued that the medical student should take the consent as an important part of their training, we feel our system maximizes the learning opportunities while avoiding patients being examined against their wishes as may have happened in the Broadmore et al. study.