Nhs students and lack of consent.

I'm all for students to be able to learn.
and in many instances I agree to students being present or even hands on.

but as redtoothbrush describes, the nhs needs to stop presumed consent and actively ask patients before inviting anyone to observe or participate.

and nhs carers/nurses/dr need to bloody start to read patient information. this is such a fundamental issue!

one of my dc was a student's midwife very first hands on birth.
but it was approached correctly. I was asked before she entered the room and it was made clear that I could refuse at any time. turns out she was lovely and supportive and her supervisor was making sure that she asked for consent for each intervention.

That’s why we have signs everywhere in our department and it is written on appointment letters, which also have text in different languages about how you can get the letter translated and request an interpreter.

Signs don't cut it. Because by the time you are in the waiting room, how do you actually action anything meaningful? Its often too late to do anything for that appointment before you might feel ambushed / unable to say no.

There should be a much more proactive engagement on this at GP level or at midwife booking ins BEFORE most people will get to the hospital / are in a vulnerable position.

A and E is an exception - and i would question certain things in that respect because you are getting lots of patients who are perhaps unable to consent.

Trading standards have a set of rules about what is deemed a hard sales practice. These include circumstances where someone is unable to freely walk away. The equivalent is incapacitated in someway in a hospital bed. Or some someone deemed vulnerable.

This doesn't seem to have been carried forward into medical settings - it took enough to challenge bloody Bounty on this score. Why weren't hospitals on the ball with that? For the same reasons that they aren't fully thinking about undue pressure for consent.

Would it be fair to say that most people would be happy if the doctor/ nurse met you on the way to their room and asked before you entered?

This as the minimum default. But I also think in certain cases there should be a warning that is clear on records that certain patients are not suitable for this and have an expressed wish that they are not asked or they are deemed too vulnerable to be asked.

So two good layers of safeguarding.

@RedToothBrush Not sure why you addressed my post. I was responding to someone who said it was selfish. I wasn't the one that said it was selfish!

I'm a doctor, and I'm utterly horrified at what some of you have endured- I'm so sorry. I think it's clear that different people have different ways that they would prefer for consent to be discussed. Would it be fair to say that most people would be happy if the doctor/ nurse met you on the way to their room and asked before you entered? I know a few people wanted to see the student to gauge how they felt, but I think that was a minority compared to the people who felt that added pressure.

With regards to 'they have to learn', yes we do; but we don't have to learn at the cost of the patient's comfort. There are enough women out there who've had a few babies and now don't mind who watches, that the minority who aren't comfortable shouldn't feel like they HAVE to allow it to facilitate our learning. I watched but didn't do any vaginal exams as a student- I knew I was going to do a specialty that would never involve VEs, and my training has not suffered one bit because of it.

Did you miss the part about the letters having information on how they can be translated? The information is given prior to the observer arriving because it’s on the letters sent to patients which can be translated into their language if they don’t speak English, so they know ahead of the appointment that there may students there as it’s a teaching hospital and they can decline if they wish to. It’s not just sprung on them when they turn up.

A fifth of people in the UK are considered functionally illiterate. Letters simply may not cut it.

A student midwife saved mine and my daughters life. She went against the midwife's advise and hit the wall alarm when she could see I was becoming upset at being ignored but the midwife. It was the right call as my daughter was stuck and needed her shoulder dislocating and resuscitation when she was born.

Patients do have to take some level of personal responsibility for speaking up for themselves as well, and if they’re unable to for whatever reason then they should bring an advocate with them, because as patient you could feel pressure to agree to anything in a healthcare setting for many reasons and it’s important for us a HCP to know that when you’re consenting you actually do want to consent and it’s not just because you feel too scared to say no or show that you’re hesitant.

Anyone tried to do this apart from me?

Its harder than you think - even prepandemic. How do you insist on this if you are staying overnight in hospital for example?

With respect to anyone suggesting this as an option, don't talk out of your ignorant backside.

Even with it written all over my notes in big letters that I suffer from severe health anxiety and trust issues with HCPs, there have been occasions where this has been utterly ignored with people who have failed to read my notes. There was one occasion where this caused an incident which led DH to put in a formal complaint because I was so distressed about it (and didn't feel I could do it myself). My complaint was upheld - and it turned out the person in question was already subject to an investigation about their conduct with patients.

I have found the pandemic to be utterly terrifying from this point of view. There are reasons where I probably should have gone to the doctor but because you are not allowed and advocate (and trying to get an exception is nightmarish). Its led to me avoiding health care settings.

Its fine to an extent now, but going forward it could be more problematic.

My anxiety was caused by poor practice to begin with so isn't just a fantasyland 'oh you should get councilling' thing.

I want it taken seriously that consent matters and is a priority not an afterthought. I want it so that you can have a blanket opt out, so you don't fear the rigmarole of everytime having to 'defend yourself' and be assertive. I want it identified that there are certain vulnerable patients who should never be put in the position to be effectively taken advantage of in a system that doesn't recognise certain traumas. This is a modern health service for gods sake - if its blind to the mental health impacts of this, it shows just how fucking far its got to go.

There is an institutional level problem with this where its not seen as legitimate to recognise there is an issue with ensuring there is safe consent giving, and adequate thought given to patients saying yes because they feel they have to, not because they want to.

I have expressed this in writing. And I've still had situations where they have ignored it or had HCPs speak to me in a way that has been problematic and they have subsequently admitted was fair comment.

It frustrates me deeply that its a battle to even get it acknowledged rather than getting condescending, patronising, dismissive and sometimes down right cruel comments about how you should just suck it up. I have a diagnosis. I have a recognised anxiety over this. The advice I've been given is that i need exposure over a period of time, to let me regain trust in the system. And its worked to a point - only for individuals with poor attitudes to go and fuck it all up again.

I am better than I was. But my recovery actually depends on people actually doing things properly and not assuming consent or telling me they will be doing something rather than seeking my consent. Its literally my trigger. And I very very much doubt that I am unique. I'm just the one articulate and bloody minded enough to be able to write this down. In person, it all completely crumbles, i get forgetful and have a problem with going completely mute.

So yeah. It matters.

And utter ignorant shit saying 'oh just take someone with you' is so disconnected with reality that its actually painful to read.

Get your heads out your arse and bother to recognise that health anxiety is real, it leads to health care avoidance and that in turn leads to poorer physical outcomes. Its recognised as a medical problem - a form of anxiety - that you can just snap out of. The system is structured to not understand this and it makes everything a far bigger battle than it should be.

[quote notanothertakeaway]@SC215

"My name is Adam, is it ok if I observe?" would be so much better than "My name is Adam. I'll be observing. Is that ok?"

Patient consent shouldn't be assumed

Yes, everyone has to learn somewhere, but I expect there will be enough people who do consent[/quote]
No, that conversation should be between the patient and their consultant beforehand, and the patient’s decision communicated to the students.

The patient should not be expected to say no to the students at the start of the consultation. As we’ve seen on this thread, there are people who expect the patient to say yes as long as they are asked, because they somehow think it’s the job of the patient to ensure students get sufficient hands-on training.

@SC215

"My name is Adam, is it ok if I observe?" would be so much better than "My name is Adam. I'll be observing. Is that ok?"

Patient consent shouldn't be assumed

Yes, everyone has to learn somewhere, but I expect there will be enough people who do consent

If there are examples on the thread where people are assuming students then that’s on the heads of the professionals who haven’t bothered to clarify things.

Rather than go against the OP’s (or anyone’s) point about properly informed consent, it rather makes it I’d say.

OrangeShark27 Are you saying that the patient's consent is not required for trainees to perform a procedure, wheras it is required for students?

I would say there's a lot of confusion on this thread between students and trainees. A trainee doctor is literally anyone up to a consultant. A registrar who is about to do their consultant exams is still a trainee even though they may have many years of experience.

For example a trainee GP could have many years of experience as a doctor behind them but is undergoing their GP training. One of my friends has been a doctor for 10 years has just begun their GP training.

People described as trainee dentists in practice are fully qualified dentists, in their first year of qualification. They are not students. They will have carried out all dental procedures many times, in dental school. But have a trainer around if needs be for their first year in practice.

Ward rounds have the full team on them not for training purposes but so everyone involved in the patients care knows what's going on and can combine their info. For example the more junior doctors are likely to be the ones who know say the blood results, or who will be writing up the notes/drug charts/ordering scans. The registrars examining and the consultants making the final call. I have been on ward rounds with 4 consultants who can all combine their knowledge/opinion to ensure the patient gets the best care. More junior doctors can be valuable in the decision process.

Frequently a 'trainee' may sit with a consultant - this can frequently be a fully qualified doctor. I have worked with other people of the same level purely because they were free to assist or chaperone.

A lot of the scenarios in this thread are not students

Also makes clear that there are numerous people on this thread who work in healthcare and who do not understand ethics and consent, which is quite alarming.

Anyways, I'm stepping away from this now, or I'll be awake all night, thinking 'and another thing!. . . ' Yes, that's what a saddo I am.

Night all, thanks for the interesting discussion.

Which goes somewhat against the lassez faire attitude of 'well, you can't please everyone'. . .

And once again - there's a lot of reasons why people can't read signs, so signs in and of themselves, do not discharge the obligation to ensure a patient has provided informed consent. Ditto with letters.

Also, that, from the BMA is quite explicit that where possible, patients should be given the option of considering the request prior to the arrival of the observers.