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Medical students learning intimate examinations without valid consent: a multicentre study

Medical students learning intimate examinations without valid consent: a multicentre study
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  Medical students learning intimate examinationswithout valid consent: a multicentre study Charlotte E Rees 1 & Lynn V Monrouxe 2 OBJECTIVES  This study aimed to exploremedical students’ explanations of their behav-iour when instructed to observe or performintimate examinations or procedures without  valid patient consent. METHODS  We used a qualitative designemploying individual and group interviews toelicit narratives of dilemmas associated withprofessionalism. Qualitative thematic analysesof narratives were followed by a qualitative andquantitative analysis using a validated codingscheme of students’ explanations of theirbehaviours within dilemmas involving intimateexaminations carried out without valid consent.Participants ( n   = 200) were medical studentsdrawn from each academic year of three med-ical schools, representing two 5-year under-graduate programmes and one 4-year graduate-entry programme in England, Wales and Australia. RESULTS  Of 833 narratives collected, 112involved dilemmas associated with intimateexaminations. Of these, 63% ( n   = 71)described dilemmas which came about becausestudents were instructed to observe or performintimate examinations or procedures without  valid consent. A total of 82% ( n   = 58) involvedstudents complying with instructions andcontained 349 distinct explanations. Thirteennarratives described cases in which studentshad refused to comply and contained 84explanations. A high proportion of explana-tions of compliance included statements by students that they ‘had to’ observe or performthe examination or procedure. Explanations of compliance behaviours significantly down-played the intentionality of actions, whereasexplanations of refusal emphasised intention-ality ( v 2 = 14.225, d.f. = 2, p = 0.001). CONCLUSIONS  Despite clear policies at eachschool, students in all schools observed orperformed intimate examinations or proce-dures without having gained valid consent fromthe patient. Faculty development initiatives areclearly essential to help clinical teachers put intimate examination policy into practice. learning from patient contact Medical Education 2011 :  45  : 261–272  doi:10.1111/j.1365-2923.2010.03911.x 1 Centre of Medical Education, College of Medicine, Dentistry andNursing, University of Dundee, Dundee, UK 2 Division of Medical Education, School of Medicine, Cardiff University, Cardiff, UK Correspondence:   Charlotte E Rees, Centre of Medical Education,College of Medicine, Dentistry and Nursing, University of Dundee,Tay Park House, 484 Perth Road, Dundee DD2 1LR, UK.Tel: 00 44 1382 381971; Fax: 00 44 1382 645748;E-mail: ª  Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011;  45 : 261–272  261  INTRODUCTION For consent to be valid, it must be given freely by anappropriately informed patient with the capacity toconsent. Validity is easily threatened if the patient lacks capacity, has inadequate understanding of thenature and purpose of the procedure, is asked forconsent at an inappropriate time or is coerced. 1,2 In2003 the  British Medical Journal   published the resultsof a survey at one UK medical school in which 24% of intimate examinations of anaesthetised patientsrecalled by students had been undertaken without  valid consent. 3  Additional comments showed that, onmany occasions, more than one student examinedthe same patient and many students felt unable torefuse a senior clinician’s request or to express theirdiscomfort. An accompanying editorial declared that ‘identifying the problem is only half the battle: theother half is coming up with an effective solution’. 4 The first step towards such a solution is that medicalschools should develop, implement and evaluatepolicies on learning intimate examinations. 4 Roughly a decade has passed since the data collectionby Coldicott   et al. 3 and many medical schools havedeveloped comprehensive policies. However, in thispaper we report data which demonstrate that students are  still   being asked by senior clinicians toconduct intimate examinations without valid patient consent, sometimes in contexts in which multiplestudents examine one patient, and that most studentsstill feel unable to refuse such requests. Furthermore, we suspect that this problem is prevalent across theclinical workplace, affecting medical schools acrossthe UK and elsewhere. 5 Unlike Coldicott   et al. , 3  we did not set out to explorestudents’ experiences of learning intimate examina-tions with patients. Rather, we employed a narrativeapproach in individual and group interviews withmedical students at three schools in different coun-tries with the intention of increasing understandingof the range of professionalism dilemmas they expe-rience, their behaviour during the various dilemmasituations and their explanations for such behaviour. As we typically make sense of our experiencesthrough the social act of storytelling, 6 the analysis of students’ narratives (which include their explanationsof behaviour) enables us to explore how studentsmake sense of these difficult experiences and how they manage that sense-making process throughsocial interaction. Although we never specifically asked about learning intimate examinations, students volunteered narratives that described situations in which they had been instructed by senior clinicians toobserve or perform intimate examinations or proce-dures without valid consent and provided myriadexplanations for why they had complied with orrefused such requests.In his editorial, Singer alluded to the thorny issuesof systems and culture; recognising the need for‘systemic solutions’ and ‘deep cultural change’. 4 By examining medical students’ narratives of intimateexamination dilemmas and the behaviouralexplanations within them, we should progress onestep closer to understanding why students conduct (or refuse to conduct) intimate examinations without  valid consent and how these behaviours are socially constructed and ultimately legitimised. Not only willthis help us to better understand the gap betweenintimate examination policy and practice, but it should also help us advance towards possible systemicsolutions and, ultimately, cultural change. Behavioural explanations ‘Behavioural explanations are in the mind  when people try to find meaning   in the stream of behaviours andevents around them, and behavioural explanationsare  social actions   when people use them for persua-sion, communication and impression management.’Bertram Malle 7  When we explain our behaviours to others, we engagein a process of sense making (both for ourselves andfor others). During this sense-making process, we aremotivated to provide a convincing account of eventsthat portrays us in a positive light; this is never moreimportant than when we explain socially unacceptablebehaviours such as compliance with instructions toconduct intimate examinations without valid patient consent. Drawing on the folk conceptual theory of behavioural explanation 7 and its associated validatedcoding scheme 8 enables us to explore the different types of explanations people employ to account fortheir behaviour and to manage social interaction.This sophisticated theory of behavioural explanationis useful because it considers both the  whats   and  hows  of behavioural explanation. In terms of the  whats  , it focuses on the content of explanations representedby those factors believed to influence behaviour suchas agent (i.e. self), other person and situationalfactors. 7,8 In terms of   hows  , it focuses on how behavioural explanations are articulated for, amongst other things, impression management purposes. Thisimportant aspect of the  social act   of explaining 262  ª  Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011;  45 : 261–272 C E Rees & L V Monrouxe  behaviours can shed light on how both positive andnegative behaviours can be legitimised within certaincommunities. 9 Thus, by focusing on the  hows  , the theory differenti-ates one mode for explaining unintentionalbehaviours (Causal Explanation) and three modes forexplaining intentional behaviours (Reason, CausalHistory of Reason [CHR] and Enabling Factor [EF]explanations). Table 1 shows a description of explanation types. As this study examines only explanations of intentional behaviour, we do not talkabout Causal Explanations here. When explainingintentional behaviour, people usually provide aReason explanation first. 7  Although Reasons high-light thespeaker’s intentionality, this can bemitigatedthrough the use of language. Consider the two belief explanations in Table 1, which are identical except that the first is marked with the mental state ‘I think’.The inclusion of the mental state marker explicitly highlights the subjective intention for the act (in thiscase, the intention to act on a rare opportunity). Theomissionofthismarker,however,givestheimpressionthat the belief refers to an objective fact rather than asubjective opinion. The intentionality of actions canalso be downplayed by the citation of other factorsthat impinge on one’s behaviour – such as CHRs orEFs – or by citing obligations to act: ‘... I had to   because the consultant told me to. ’ Phrasing the request as animperative effectively obscures the intentionality behind the act: the intentionality that is obscuredhere is ahigher-orderdesireonthepart oftheactor tofulfil the perceived obligation to obey the request.  Aims Using this theory of behavioural explanations, thispaper aims to explore: (i) the factors students cite when explaining their compliance with or refusal of instructions from clinicians to observe or performintimate examinations or procedures on patients without valid consent, and (ii) how students explaintheir compliance and refusal behaviours as a socialact, and thus to provide insights into how suchbehaviours are legitimised through social interaction.Our expectations of findings with reference to thefirst aim are open in terms of the factors students will use to explain their behaviours. However, withregard to the second aim, we expect to see differ-ent patterns of explanation types (in line with thetheory) when students explain their compliancecompared with their refusal behaviours: 1  We expect to find fewer Reasons and more CHRsand EFs in explanations of compliance than inexplanations of refusals. We expect that this willreflect students’ motivation to downplay theirintentionality for the act of complying with aclinician’s request and to highlight forces outsidetheir control that impinge on their behaviour,thereby effectively legitimising such behaviour. 2  We expect that, when Reasons are cited, moredesire-based Reasons for explanations of com-pliance and more belief-based Reasons forexplanations of refusal will emerge. Students whoexplain compliance behaviour may wish to: (i)put a positive spin on their negative action by suggesting some nobler cause for theirbehaviour, such as the desire to learn, thereby providing further legitimisation, and (ii) down-play intentionality by constructing their actionas a higher-order obligation (therefore desire). Table 1 Description of explanation modes and types Reason Mode of explanation in which the narratoridentifies salient features of his or hermental state underpinning his or her intention  to actBelief reason Belief refers to events the speaker believesto be true: ‘I did the intimate examinationbecause  think the opportunity for thisrarely arises ’Desire reason Desire refers to objects or events that thespeaker wants to see realised: ‘...because  wanted to learn ’Valuing reason Valuing indicates positive or negativeaffect towards the action or its outcome:‘ ... because I  on’ tlike  saying no toconsultants ’Marked belief Belief marked with the mental state:‘... because I  think the opportunity for this rarely arises ’UnmarkedbeliefBelief omitting the mental state marker:‘...because  the opportunity for this rarely arises ’Causal historyof reason(CHR)Mode of explanation in which the speakerrefers to background factors away fromhis or her in-the-moment deliberations:‘...because  I lacked the confidence torefuse ’Enabling factor(EF)Mode of explanation in which the speakerhighlights external factors that enabledthe action to occur: ‘...because  the nurse supervised me ’ ª  Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011;  45 : 261–272  263 Intimate exams without valid consent  By contrast, we expect that students who refuserequests will be motivated to highlight theintentionality of their actions. 3  We expect to find more unmarked Reasons inexplanations of compliance (again, to downplay intentionality) and more marked Reasons inexplanations of refusal. METHODS Design This qualitative paper reports on part of a larger study exploring dilemmas associated with professionalismexperienced by medical students in the context of events during their learning in which they observed orparticipated in something they thought was unethi-cal. 10  Although previous research 11,12 has exploredstudents’ reasoning processes in the face of profes-sionalism dilemmas, these studies analysed students’ written narratives (and their associated reasoning); written narratives were also intended for assessment purposes and thus can be seen as ‘crafted confes-sions’. 11 However, we were interested in collectingstudents’ oral narratives of lived experiences and inexploring how students explained their behavioursduring these dilemmas to researchers in or outwiththe presence of their peers. Because of the sensitivenature of the topic of inquiry, we gave students theoption of participating in individual or groupinterviews. Context  The three medical schools in this study are based indifferent countries (England, Wales and Australia)and apply different entry requirements and curricula.In their written policies for medical students’ learningof intimate examinations with patients, all three statethe importance of gaining valid patient consent tostudent involvement in the observation and perfor-mance of intimate examinations, although one schoolsuggests that patient consent is not always necessary inthe case of student involvement in patient manage-ment. The other key difference between the policies isthat two of the schools provide guidelines on how students should handle ethical breaches regardingintimate examinations, but one school does not. Participants Following ethics approval from the schools, studentsacross all years at each school were invited toparticipate. Students were introduced to the study through face-to-face announcements during lecturesor small-group tutorials, e-mail invitations, informa-tion posted on virtual and actual noticeboards, andinvitations disseminated through other students whohad already consented to participate (i.e. snowball-ing). All students were required to read the partici-pant information sheet and to sign a consent formbefore taking part. Participants were able to withdraw from the study at any time without penalty.Two hundred medical students (87, 38 and 75 fromSchools 1–3, respectively) participated in 32 groupand 22 individual interviews. Most students were aged20–24 years ( n   = 118), were female ( n   = 120) and were White ( n   = 167). (Monrouxe  et al. 13 givesfurther details about the demographic andeducation-related characteristics of the participantsin the study.) Data collection  All group and individual interviews were digitally audio-recorded with participants’ permission. Theinterviews began with the orienting question: ‘What is your understanding of professionalism?’ (Responsesto this question are presented in Monrouxe  et al. 13 )Following this, narrative interviewing techniques wereemployed to collect student narratives of incidents in which they had personally experienced professionalismdilemmas as medical students. The researcher usedgeneral open-ended questions and did not specifi-cally ask about intimate examinations. When narrat-ing their professionalism dilemmas, studentsfrequently included explanations of their behaviours.If these were not forthcoming in the narrative, theinterviewer explicitly asked narrators to explain why they had behaved in the way they did. Data analysis The audio-recordings were transcribed and anony-mised. Transcripts and audio-recordings were first analysed using framework analysis. 14 (Monrouxe et al. 13 gives further details about the coding frame- work.) This first-order thematic analysis resulted in acoding framework comprising five higher-orderthemes relating to what participants said (e.g. defi-nitions of professionalism) and seven relating to how they spoke (e.g. emotional talk). Of interest to thecurrent paper is the second theme, labelled ‘medicalstudents’ dilemma situations’, which resulted in thecoding of 833 personal incident narratives. Includedin this main theme was a sub-theme that referred tostudent dilemmas that arose in the context of  264  ª  Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011;  45 : 261–272 C E Rees & L V Monrouxe  learning intimate examinations. This comprised 112narratives. Note that although considerable cultural variation exists in terms of which parts of the body areconsidered intimate, we focused on three main body regions for our coding of ‘intimate examinations’:the female breasts; the genital and inguinal regions of males and females including the female pelvicorgans, and the rectum of males and femalesincluding the prostate of males. 15,16  A total of 63% ( n   = 71) of the intimate examinationnarratives focused on issues of informed consent. Thesubstance of other dilemmas included students witnessing inappropriate behaviour on the part of qualified health care professionals during intimateexaminations, students feeling embarrassed andincompetent to carry out intimate examinations, andfamily members making inappropriate sexualremarks during intimate examinations. Interestingly,in all of the consent-related narratives, students toldus that they had been instructed to observe orperform an intimate examination or procedure on apatient without valid consent and therefore weobtained no narratives of situations that had beeninstigated by the students themselves. We thereforeconducted a second-order analysis of these 71narratives to explore how students explained theircompliance or refusal behaviours.Using Malle’s F.Ex validated coding scheme, 7,8  weidentified and coded all of the explanations withinstudents’ narratives according to the following ques-tion: ‘Why did you observe or perform intimateexaminations or procedures without valid consent or why did you refuse?’ Each explanation was coded by the first or second author. Over four-fifths of thecoding (i.e. 61 narratives, 86%) was double-checkedby the other author and disagreements werediscussed and negotiated. We retained a qualitativeprocess-oriented perspective despite using numbersto identify patterns in our data. 15 For example, inorder to address the first aim – of establishing thefactors cited by students in their descriptions of actsof compliance or refusal – we calculated thefrequencies of Agent, Other Person and Situationfactors cited within CHRs, Reasons and EFs andexplored the differences for compliance and refusalbehaviours using chi-squared tests. To address thesecond aim, which referred to how studentsexplained their behaviours, we established thefrequencies of different modes (i.e. CHRs, Reasons,EFs) and types of explanations (e.g. belief reasons,marked or unmarked) and employed chi-squaredtests to explore the relationships between these andstudent acts of compliance versus refusal. RESULTS Of the 71 narratives, 51% ( n   = 36) described vaginalor rectal examinations. A total of 54% ( n   = 38) of patients who underwent intimate examinations orprocedures were female and 52% ( n   = 37)of patients were conscious during the examination orprocedure. The most common setting for theintimate examination dilemmas was surgery (42%, n   = 30). Of the 71 narrators (some students narratedmore than one dilemma), 53% ( n   = 38) were female.Overall, 82% ( n   = 58) of narratives described thestudent’s compliance with instructions to observe orperform an intimate examination or procedure without valid patient consent. Table S1 (online) givesfurther contextual details about dilemmas accordingto students’ compliance and refusal behaviours.Fifty-five students gave 58 narratives of complianceand 12 students gave 13 narratives of refusal. Usingthe F.Ex coding scheme, 349 distinct explanations were identified in the 58 compliance narratives and84 distinct explanations were identified in the 13refusal narratives. Regarding the content of compli-ance explanations, high proportions of CHR andReason explanations cited Agent factors (66% and70%, respectively), whereas high proportions of EFscited Other Person factors (68%;  v 2 = 40.773, d.f. = 2,p = 0.0001). Figure 1 shows further details. Amongthe Reason explanations given, the most noteworthy is the high proportion of Agent obligations cited by students, such as: ‘Just had to go with it’ (Y4FS45,School 2). Other Agent factors cited within Reason 66% 70%24%27%40%68%35%44%37%EFReasonsCHREFReasonsCHRAgent Other personSituation31%53%62%19%62%69%44%67%39% (a)(b) Figure 1  Percentages of content within explanation typesfor (a) compliance and (b) refusal narratives. CHR = Cau-sal History of Reason; EF = Enabling Factor ª  Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011;  45 : 261–272  265 Intimate exams without valid consent
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