Intimate examinations and other ethical challenges in medical education

Medical schools should develop effective guidelines and implement them

Education and debate p 97

In this issue, Coldicott et al report an exploratory survey that shows, among other findings, that up to a quarter of intimate examinations in anaesthetised or sedated patients seem not to have had adequate consent from patients (p 97).1 This paper will generate a firestorm of controversy, wide media interest, and perhaps even calls for a public inquiry. Through the controversy, let us keep one point uppermost in mind: identifying the problem is only half the battle—the other half is coming up with an effective solution.

The fact that this report has been published at all represents a triumph of academic freedom. In particular, Coldicott, a medical student, deserves high praise for seeing this controversial study through to publication. The medical school examined in the study is probably not the only medical school in the world with similar practices, and the authors and their institution have done patients and the medical community a service by highlighting this problem.

The issue of intimate examinations is the tip of a much larger iceberg related to ethical challenges in medical education. In 2001 a group of medical students from the University of Toronto published in the BMJ a study on the ethical dilemmas that shape medical students' ethical development.2 The study identified the sort of conflicts between medical education and care for patients that are the focus of the Coldicott study. It also identified two other types of ethical challenges: responsibility exceeding a student's capabilities and involvement in care perceived to be substandard.

Although the Coldicott study found that 17 of 25 medical schools in Great Britain had a formal policy on teaching vaginal examinations, a broader policy approach to the ethical challenges in medical education is required.

Doyal has presented a policy on the rights of patients in medical education developed at Barts and the London School of Medicine and Dentistry in the United Kingdom.3 This pioneering policy emphasises patients' rights to consent to educational activities and to expect that information gained in the course of educational activities will be kept confidential. Importantly, the policy places a positive obligation on students and teachers to follow the guidelines: “Encouraging students to ignore these guidelines is unacceptable.”

As a result of the 2001 BMJ publication, the University of Toronto and its affiliated teaching hospitals developed guidelines for ethics in clinical teaching.4 These build on the guidelines from Barts in two important ways that are relevant to the Coldicott study.

Firstly, the guidelines highlight the responsibility of clinical teaching staff to serve as appropriate role models to trainees for ethical practice and to provide trainee healthcare professionals with an opportunity to discuss an ethical or difficult situation.

Secondly, the guidelines require the university and teaching hospitals to develop processes for reporting ethical concerns. They also require that trainee healthcare professionals and clinical faculty are aware of individuals they could approach with ethical concerns and have the right to consult with a bioethicist or consultant in clinical ethics. When a trainee expresses concern about ethical issues, refuses to participate in activities related to care for patients or clinical teaching on the basis of ethical grounds, or seeks consultation on an ethical issue, this will have no repercussions for the trainee.

The value of any guideline is not in how artfully it is crafted but in how well it is implemented and what effect it has. This is particularly critical in an area such as the role of ethics in medical education, where the informal curriculum reigns, and deep cultural change is needed.

In considering the Coldicott study, we should follow the lessons of the medical error movement, since the paper reports a type of ethical error in medical education. Rather than seeking to fix blame, we should try to find systemic solutions to the ethical challenges of medical education. Each medical school should develop and implement guidelines for ethics in clinical teaching, evaluate their impact, and share the findings of these evaluations.