Health: When it's the vagina, use a personal touch: Rob Stepney explains how medical students are gaining vital examination experience tactfully

Medical schools are adopting a more sensitive approach to teaching vaginal examination. Teaching students to examine the vagina using unconscious women who have not given their consent has been the tradition in British medical schools. It is a practice that is ethically unacceptable, legally questionable and of uncertain educational value.

Thankfully, the traditional approach is changing. But it was not until last year that the British Medical Association issued guidelines making clear that anaesthetised women must not be used as unconsenting teaching tools. The BMA's handbook Medical Ethics Today now contains the explicit statement that teaching hospitals should obtain prior written consent for vaginal examinations on anaesthetised patients.

Gynaecologists at Dudley Road Hospital in Birmingham were among the first to introduce express consent. The move followed research which showed, without exception, that women objected to not being asked.

'We now make clear that only one medical student will perform the examination and we require that the student introduces him or herself to the patient beforehand,' says David Luesley, senior lecturer in obstetrics and gynaecology at Birmingham University. Following this frank approach, only 10-15 per cent of women refuse permission.

Learning vaginal examination is a vital part of a doctor's training. It is a skill necessary in taking a cervical smear, in investigating most gynaecological complaints, in many family planning procedures, and in the care of women in pregnancy and labour. A decade ago, when the issue of consent to examination under anaesthetic was first raised, gynaecologists argued that their ability to teach would be jeopardised by any change in practice. This has not happened.

'If anything, the system now makes teaching easier, since everyone feels more comfortable,' Mr Luesley comments. 'We have proved we can adopt explicit consent without compromising training.'

This view is confirmed by Richard Beard, professor of obstetrics and gynaecology at St Mary's Hospital Medical School in London. In the St Mary's department the standard consent form for anaesthesia now asks women if they will give permission for up to two medical students to examine them in the operating theatre. 'In six years, only three women have refused,' Professor Beard says. 'It is important to show respect for patients, and this has not interfered with the need to teach.'

Change has also been welcomed at the Addenbrooke's Hospital medical school in Cambridge. 'In some teaching hospitals, it used to be that as many as half a dozen medical students would line up to examine a woman under anaesthesia,' says Steve Smith, professor of obstetrics and gynaecology. 'Now a student in our hospital is allowed to examine a woman under anaesthesia only if he or she has personally asked the patient's permission beforehand.

'The change is a good example of the need for the public to raise issues which some gynaecologists had not even thought of, and for the profession to be responsive.'

Jean Robinson, a lay member of the General Medical Council for 14 years, has closely followed the issue of consent to gynaecological examination. She believes the growing number of women in medicine has also played a vital part in changing attitudes.

'Obstetrics and gynaecology is still male-dominated, and that is not the way the public would wish it,' she says. 'But the teaching of vaginal examination has benefited from women medical students raising the issue. Now that women form half the medical school population, you no longer have to become a pseudo man to survive.'

Nevertheless, Mrs Robinson is still concerned about the 'quality' of consent obtained from patients. 'Many women feel they are not in a position to refuse,' she argues.

It may be that American experience has something to offer here. Richard Wakeford, a specialist in medical education from Cambridge University, collaborated in a survey of students from the United States and Britain to find out how they had gained their first experience in vaginal examination. Forty-six per cent of the UK sample said it had been on an unconscious patient. In America, the figure was 2 per cent. More than two-thirds of the US sample had first been taught the skill with the co-operation of a volunteer who was not a patient.

These women, termed gynaecology teaching associates, are informed, experienced, relaxed and live mannequins, ready to tell the students if they are feeling what they are supposed to feel, whether or not it hurts and, above all, whether the student's manner is going to put the patient at ease or have her run sobbing from the clinic never to return.

Most of the teaching associates are health professionals or graduates in behavioural science. They fall into two categories: the completely healthy, so that the range of natural variation can be experienced, and those with abnormal conditions. The use of such surrogate patients has spread to more than 50 medical schools, and initial assessments of students who learn from them showed an advantage over traditional methods.

The issue also raises questions of sexual discrimination. Male rectal examination, crucial to the detection of prostate cancer, is taught in urology clinics, and sometimes, in Britain, also in the operating theatre using anaesthetised patients. Though the sensitivities may not be quite the same as with vaginal examination, this aspect of current practice may also come into question. In the US, hired subjects now teach examination of the male genitalia and rectum as well as examination of the vagina. Could the hired teaching associate be helpful in this country?

David Luesley agrees that it is valuable to have someone who can explain in clear terms what is comfortable and what is not. But he has his doubts about adopting the American system. One concern involves finance. 'In the United States, teaching associates are paid, and it is not clear where the resources would come from in this country,' he says. 'It would not be good if the money were to be diverted from patient care.'

His other concern is the artificiality of the situation. 'Though well-trained instructors would be able to give good feedback on what hurts, they would probably not show the same anxiety and embarrassment as a typical patient. Overcoming this, as much as learning the anatomy, is crucial to the skill of vaginal examination.'

A further possibility is the use of inanimate models to teach basic reproductive anatomy. Such teaching tools are becoming increasingly sophisticated. Interchangeable parts can be inserted to simulate conditions such as fibroids and ovarian cysts; and there are different models to represent the genital tract of women who have not given birth, those who have had children, and those who are postmenopausal.

But such models do not protest at clumsy fingers, nor provide a guide to good bedside manner. None the less, Andrew Caulder, professor of obstetrics and gynaecology at Edinburgh University, has found them helpful in teaching the basics. His department has spent pounds 6,000 on four mannequins that are used both for instructing students in female anatomy and for testing their skills.

No one denies that adequate 'hands on' experience with real patients is essential to the training of doctors both in the mechanics of medicine and in its social skills. But doctors seem to be accepting that our sexual bits and bobs are more emotionally charged areas of anatomy than most and are making efforts to adapt their teaching practices accordingly.