Nhs students and lack of consent.

[MarbleQueen]

I’m wondering if something has changed within the Nhs. At one time you were asked if you minded having a student being present.In my area they are present at every appointment without any discussion and I’m getting fed up with it.

In the last two years these things have happened.

A student midwife was brought into my room and participated in my delivery without any discussion. She was instructed to break my waters and deliver my baby without any discussion with myself. The midwife focused on talking her through things instead of supporting me. I was alone because of covid restrictions. I later discovered it was the first baby she delivered. I felt like a piece of meat.

I went for a smear and when I walked in the room there was a nurse and 3 very young women present. When I asked who they were I was told they were trainee health care assistants. I objected and the nurse insinuated I was being a bit silly and shy. I left that appointment without it being done.

I had a dentist appointment for my first ever dental treatment. I told them I was nervous. Again when I went in, I was told, not asked that the 2 people present were dental students and would only be observing. The dentist focused on explaining things to them and actually allowed one to place the filling. I didn’t agree to this.

I went to a gp apointment for something intimate to find a man around 18 years old sat in the room. Again I had to ask who he was and was told he was a student. I had to ask for him to leave and it was really uncomfortable.

I had an apointment to have a very unpleasant procedure. There was the usual student perched in the corner without any discussion. Again I had to ask who they were and was told, not asked, that they would be observing. The doctor focused on explaining things to them and when the procedure was finished I actually realised 3 more students had been brought in to watch without me noticing.

I have previously had a type of abdominal cancer. I have checks with scans and have seen the same consultant for years. On my last visit there was the usual student perched in the corner without any discussion. On this occasion, and this occasion only, the surgeon suggested doing a VE. I asked him what information he was hoping to get from this considering he had a recent MRI scan in front of him and he simply dropped it. I strongly suspect this was going to be for the students benefit because it certainly wasn’t going to benefit me.

Each of these places have standard notices in their waiting rooms informing you that a student might be present but this is not consent. I think this is now something you have to actively opt out of instead of opting in.

Has anyone else noticed this happening? I worry about what these students are learning about consent in these circumstances.

I think most people who access healthcare know there’s a chance students may be present at some point during one of their encounters, it’s quite common, it’s happened to me numerous times as a patient, even if they don’t there are usually signs in the department stating there could be, so if they feel this strongly about not having students there and know that on the day they won’t be able to decline if the student is in the room then yes they should call ahead, tell someone on the desk or bring an advocate who will speak up for them. Alternatively, they could just ask to speak to the HCP alone when asked and decline then, there are a multitude of options available for how to decline.

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.

@AutomaticMoon

They sent flyers out to everyone in Scotland when the change happened up here. I'm sure England did something similar.

My point is, you came onto a thread about consent in the NHS and blamed them for something they did not do (the change in the law) and accused them of doing it secretly (which is not at all true; you were given a few years of warnings).

I dont like people pedaling false information.

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

What do you think could be put in place so that a patient does not feel pressured to give fake consent?

I don't assume that there will be a student present, because it isn't axiomatic, or necessarily common. Once again, you talk about signs. Signs aren't terribly useful if you cannot read them, for whatever reason, so I don't think signs by themselves completely discharge a medical practices obligation to ensure informed consent. It can be quite difficult for young patients, at their first appointments without parental accompaniment to know what is normal, what is appropriate, and to communicate reluctance or concern to an adult in a position of authority. Ditto for women who have English as a second or third language, and from cultures of deference.

It is difficult to know you should bring an advocate if you haven't been advised it could be a good idea, and you don't know that students may be present - which if you're new to a country, for example, you may not know.

I think HCP's need to take some level of responsibility, as the trained medical professional with full knowledge of their legal obligations and their practices procedures to ensure that when people are consenting, they do actually want to consent, have full knowledge of their right not to consent, and understanding of how to invoke that right.

[quote Itsalmostanaccessory]@Janesmom

We should be able to give consent.

I was asked if one student could watch while I had a pessary inserted into my vagina. I said yes. They then brought 6 of them in. I was in a the bed with the curtains drawn round, so not a lot of space. My legs open, and I had to sit like that for much longer than necessary so each student could come and have a look while the person teaching them explained what she was doing over and over again, demonstrating by putting her hand into me.

One student would have meant the procedure happend once with that student watching. Even two could have stood at the end together. But with 6, she has to do it and then imitate doing it a few times so they could all get a look. I was used as a doll basically. Do you think that is OK?[/quote]
My god, that's dreadful.

They absolutely should not be penetrating you for no clinical reason! That is definitely complaint worthy.

I wonder if the people suggesting phoning ahead have actually tried to ring their gp or hospital lately.

Some people are supporting the nhs imposing a system where consent is assumed unless you actively opt out. If that’s what the nhs are now doing then they need to say so and they should have a simple process for people to opt out.

[quote HonestwithHope1]@justlyra.

Ta. Not shifting responsibility at all but agree to disagree

Informed consent is essential. Hope we can all agree on that one[/quote]
A student in the room already, and a casual "is it OK for student to observe?" is NOT consent. Students should stay out the room until consent is obtained.

Because I've been there. I've been the patient in this situation, years ago, back when I was an anxious mess and unable to assert myself. I found myself saying Yes, when inside I was screaming for the student to leave the room. I felt pressured into having that student in the room when I didn't want them there.

These days, I'm much more assertive, but if the student is there already, it's still difficult to say "sorry, please leave the room". I was in a long, abusive relationship, and it left scars that meant I had to re-learn assertiveness after I left.

So there is much more to consent than "just say yes or no".

@MarbleQueen

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

What do you think could be put in place so that a patient does not feel pressured to give fake consent?

All we can do is follow the guidelines for informed consent and make sure that we let patients know with our communication (verbal, written and non verbal) that they are free to decline for any reason. But if people despite this feel uncomfortable declining because they perceive there to be a power imbalance or are scared of consequences and don’t communicate that there’s not much we can do. I always try to make patients feel relaxed, give them all the information I think is relevant and put them at ease before I ask for consent for anything, but I can’t possibly know what’s going on in someone’s head if they don’t tell me, some people are very passive or have a lot of anxiety about saying no to anything in a healthcare setting, but there’s not a lot I can do about that if they don’t let me know they’re uncomfortable and appear happy.

You cannot please everyone, as everyone is different, some people on here have expressed they want to see the student first before consenting others don’t, unless we get complaints about our procedure and we’re following the correct guidelines then I see no reason to create extra work for the sake of it. Personally unless it’s something intimate I have no issue with students being there, and if it was something intimate I would rather see the student first before consenting, because I would have no issue with a female student watching me have a smear for example, but I wouldn’t want a male student watching unless I felt comfortable with him, which I wouldn’t know until I met him.

www.bma.org.uk/advice-and-support/ethics/medical-students/ethics-toolkit-for-medical-students/adults-with-capacity-and-consent

"Is additional consent required for students to be present during consultations?
Yes. The doctor carrying out the consultation should explain to the patient that an observer or observers would like to sit in on the consultation, who they are and why they wish to observe.

Patients must feel able to refuse consent to the presence of students or other observers during their consultation, examination or treatment. They should be reassured that their decision will, in no way, affect their treatment. Wherever possible, patients should be given the option of considering the request prior to the arrival of the observers. (my emphasis).'

Interesting.

@mbosnz

www.bma.org.uk/advice-and-support/ethics/medical-students/ethics-toolkit-for-medical-students/adults-with-capacity-and-consent

"Is additional consent required for students to be present during consultations?
Yes. The doctor carrying out the consultation should explain to the patient that an observer or observers would like to sit in on the consultation, who they are and why they wish to observe.

Patients must feel able to refuse consent to the presence of students or other observers during their consultation, examination or treatment. They should be reassured that their decision will, in no way, affect their treatment. Wherever possible, patients should be given the option of considering the request prior to the arrival of the observers. (my emphasis).'

Interesting.

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.

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.

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

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.

@MarbleQueen

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

What do you think could be put in place so that a patient does not feel pressured to give fake consent?

HCPs need to reflect on and hone their emotional intelligence skills, as well as communication. And welcome feedback from patients, we need to be open and not defensive, as hard as that is especially these days. Perhaps the admin person at the reception desk could ask as well when the patient arrives? I'm not sure what the answers are but it's an important conversation to have.

@mbosnz

www.bma.org.uk/advice-and-support/ethics/medical-students/ethics-toolkit-for-medical-students/adults-with-capacity-and-consent

"Is additional consent required for students to be present during consultations?
Yes. The doctor carrying out the consultation should explain to the patient that an observer or observers would like to sit in on the consultation, who they are and why they wish to observe.

Patients must feel able to refuse consent to the presence of students or other observers during their consultation, examination or treatment. They should be reassured that their decision will, in no way, affect their treatment. Wherever possible, patients should be given the option of considering the request prior to the arrival of the observers. (my emphasis).'

Interesting.

Well, that is very clear. And exactly as it should be.

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.

@mbosnz

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.

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.

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

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

@OrangeShark27

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

And the onus is still on the medical professionals involved to make sure the patients know who they are seeing, why, and that they consent to it.

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.

@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 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.

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.

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.

@rainbowdashsneeze

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.

Midwife's can be tough to deal with. I've worked in a few hospitals (not as a member of medical staff) and every department will say, "oh, you dont want to mess with the midwives." So I very much hope that that student got support and wasnt bullied by the midwife she overruled.