Please don't touch me there: the ethics of intimate examinations

Editor—Coldicott et al raise several issues.¹ How do students acquire clinical skills without practising on patients? Rather than contribute to the ethical debate, we propose that alternatives be explored to support students in the development of clinical skills.

Coldicott et al recognise that technical skill is just one element of competence in vaginal examinations. The ability to communicate sensitively is crucial, and indeed each patient's definition of an intimate examination must be central. Practising on an anaesthetised patient provides no opportunity to develop communication skills and reduces vaginal examination to a purely technical task. Observing a student performing a vaginal examination provides no guarantee of what is palpated. Conventional pelvic manikins have similar limitations, but pressure sensitive manikins, fitted with electronic sensors, can provide feedback on which organs are palpated and with what force.²,³

We have developed an approach to teaching and learning clinical skills that links manikins with actors.⁴ Students integrate their clinical skills in a safe environment, gaining confidence and competence. This graduated approach ensures that students are prepared to deal with contextual challenges of real work settings.

Clinical teaching associates (women who volunteer to undergo vaginal or rectal examination and who are trained to provide feedback on technical and communication skills) are established in medical schools in other parts of the world. Including such approaches locally within curriculums may help to avoid unacceptable situations such as those described by Coldicott et al.