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.

There isn’t a sorting hat; new doctors mainly make the decision to specialise in their chosen areas on the basis of which placements inspired them during their undergraduate course and in their foundation jobs.

In order to attract highly motivated people to become the consultant gynaecologists/ psychiatrists/ oncologists of the next decades, it is important that students are exposed to these areas of practice. A good grounding in Women’s Health isn’t just for future obstetricians and gynaecologists - it’s important in General Practice, Emergency Medicine, General Surgery, Oncology, Radiology, Anaesthetics etc.

I’m a nurse. When I trained I always checked if it was ok for me to observe or carry out things myself.
As a patient there are some things I wouldn’t want more people that necessary there for. But then I did have a very traumatic experience where I almost died, and my child did die.
In any case, it would appear that there are so many people on this thread who are more than happy to allow students/juniors etc.
so the odd person saying no, shouldn’t be a problem really.

I don’t think patients smears are pay per view. In fact I said I didn’t. I’m trying to engage - I’m a woman I’ve had babies and emergency c section and the experience of what feels like 100 people run into the room to stare at you legs akimbo (and I also have to now work with some of these people day to day, gotta love having colleagues who have seen you starkers) I get it’s shit, No one should feel uncomfortable or have anyone they don’t want for any exam or procedure (other than a properly trained chaperone for intimate exams which I believe should be mandatory everywhere). That’s not debatable and I hope all medical professionals would agree. I have left many a room when a student and as I said still do now I’m qualified - when on Gynae I was always double checking it was ok for me to be there. Patients do withdraw consent mid procedure and that’s also ok. You stop straight away and if someone doesn't stop it’s assault. Usually means then a big discussion needs to happen about how we can make the procedure work better for the patient if it is essential for their health.

What has surprised me here is anger, the feeling that students are exploiting patients, that students should not automatically be involved in patient care that no one other than those essential for the provision of care should be present, and the feeling that these students are just folk off the street. This seems new, it’s talked about in medical circles but from the other side - why so many male doctors are barely competent in women health, how universities are cutting the qualification requirements for doctors as students are not getting enough exposure to certain types of patients and procedures. How trainee surgeons now days have assisted on many less cases. How newly qualified doctors don’t seem able to cannulate or insert NG tubes because they never did as students. Doctors qualifying now have less hands on training than their predecessors and that’s a worry as it seems to mean they are less competent, especially as COVID removed around a year of face to face training for the current cohort.

Also concerned that students seem so often to be thought of as disinterested. Students shouldn’t be grumpy in a corner - that is shit and hopefully they are going to be failed by their supervisor for being poor communicators, but it’s a worry there seem to be so many!

Students do practice non intimate exams on each other and also (or at least used to) learn how to take blood from each other etc. ThWhen I was a student due to lack of patients consenting to being examined, the medical school advertised for women to work as intimate anatomy demonstrators for students to learn examination on - I wonder what people think of that? It was also a big issue at some medical schools a few years ago as females from different ethnicities were not agreeing to this due to religious reasons causing upset amongst male students who felt they were being exploited by always having to be the examination models, but clearly we also want ethnic diversity in doctors. Plastic models are no substitute.

The feeling I am also getting on this thread is that people don’t realise how much students are already involved in their care and it strikes me that Most people on here would not want that, for example the students will be present when all the cases are discussed at handover, they have access to the medical records of patients, they assist in operations (provide touching the patient assistance like retracting skin layers), look at samples in the lab etc, be part of resuscitation attempts . I do not believe that consent is ever taken for this any more than it would be for a qualified team member to do these things. (This does not include intimate exam under anaesthesia - this requires separate written consent)

You should be given the choice of which nhs hospital you want your care in.

Uk medical undergraduate qualifications is a generalist qualification and then juniors doctors spend two years minimum rotating through lots of departments then they choose what type of doctor they want to be and start specialist training. A doctor must already be proficient in all the basic skills before they qualify as a doctor. This includes intimate examinations both of men and women - breast, prostate, testicular and vaginal. It does not include surgery so they would not have to perform a circumcision but does include more minor procedures such as suturing a wound and inserting a nasogastric tube. My medical school required each medical student to have delivered five babies in order to qualify but I think that might have been dropped as male students in particular were not being given permission.

So even if you want to be a psychiatrist or a knee surgeon you will have to be examined as competent in intimate examinations and then have a fairly high chance of working in obs and Gynae for a bit before you specialise. I don’t think students do think they are qualified before they are but they have to . I’m sure I’ll annoy someone with another non medical analogy but it’s like learning to drive - learners have to actually do all the stuff drivers do but with a supervisor and then when they pass their test they can do it on their own. Medical students have to learn to do all the things doctors can do because once they have passed their finals they are qualified to do it on their own from that point. Hopefully it’s reassuring to people that like learner drivers have to apply for a provisional licence medical students have to have DBS checks, ID checks, professional standards oversight, confidentiality training, resuscitation training, occupational health clearance etc just the same as the doctors do. They also have to do the same nhs mandatory learning and induction as all staff working in the nhs - they don’t just turn up from no where!

The feeling I am also getting on this thread is that people don’t realise how much students are already involved in their care and it strikes me that Most people on here would not want that, for example the students will be present when all the cases are discussed at handover, they have access to the medical records of patients, they assist in operations (provide touching the patient assistance like retracting skin layers), look at samples in the lab etc, be part of resuscitation attempts . I do not believe that consent is ever taken for this any more than it would be for a qualified team member to do these things. (This does not include intimate exam under anaesthesia - this requires separate written consent)

I can only speak for myself but I find most of those things fine. I couldn't care less about them discussing my history when I'm not there, it's when they do it in front of me and I have to deal with their embarrassment/pity that pisses me off. It's hard enough to talk to one person about anything gynecological or regarding my mental health, adding extra bodies especially males makes the scales tip further towards me being unable to do so.

Students do practice non intimate exams on each other

Why only non intimate?

@PearPickingPorky

Students do practice non intimate exams on each other

Why only non intimate?

Yeah if it's no big deal and we're all supposed to be happy to be their Guinea pigs, why don't they volunteer too?

Hmm..... anyone would think that just maybe, it's actually a bigger deal than some would suggest!

The solution for me would be to have specialists in women's sexual health / gynaecology within primary care rather than expecting all GPs to be able to do intimate exams well. Which would mean ongoing training etc. Specialists could work across practices.

The previous poster who said GPs are also being expected to perform prostate exams etc may be true but based on my older family members experiences of prostate issues, the GPs have taken a history and immediately referred on rather than doing any examinations themselves.

Indeed.

Either "it's just a body, no need to be embarrassed, they're students who want to be doctors!" and therefore this minor inconvenience is necessary...

Or it is actually quite a big deal and quite a lot to ask of someone when there is no benefit to them as an individual. And particularly a lot to ask when that patient is in the vulnerable position of being very unwell and under a lot of stress and upset.

In which case, since the benefits of medical students having access to bodies to practice on lies with the medical students themselves, then it is they who should offer up their bodies for practice. It will be much less of an issue for them to do it than patients, because a) the students themselves are benefitting, b) they are not ill so are not vulnerable like the patient is, and c) they are able to compartmentalise it as "just a body, no big deal, no need to be embarrassed" better than your average Josephine on the street can, so it won't cause them any psychological discomfort.

Yet that doesn't seem to be the case, which tells us something.

Sorry, that was in reply to Lumos.

1. The reason students need to examine patients after they have learnt the techniques on each other/models/volunteers is they need to see pathology. Medicine may be all fancy and technological but most of it still is pattern recognition- seeing/feeling/hearing lots and lots of normal and abnormal whatevers (heart sounds/prostates/wombs/ear canals) - fortunately students tend to be a healthy lots so there’s not much pathology to find

1. Never said it’s not a big deal to have students there. It is. Nor that consent should not be sought. Am trying to challenge the idea that students should not be present in the department/clinic at all.

1. The body is connected - sorry if this sounds patronising. Ovarian cancer is missed because people and their doctors think it’s their bowels or their bladder - removing gynaecology from the medical school curriculum is not going to help this.

1. There are not enough gynaecology specialists to staff the existing clinics. There is a crisis in gynaecology training. Not enough people want to train in it and not enough opportunities to gain the needed experience. I don’t know any male UK graduates in Gynae training. Most say it’s because they realise they are not welcome or wanted by the patients and can’t get any experience.

To make this perfectly clear IT IS NOT THE INDIVIDUAL PATIENTS JOB TO MAKE THEM FEEL WELCOME. Currently we have unhappy patients and not enough doctors- not sure the solution to this is going to be to have the students examine each other.

I would incentivise women to train in gynaecology. Big pay incentives and other benefits etc.

Never going to happen in a million years for a variety of reasons, mainly that women are never prioritised in anything, but incentivising women to specialise in gynaecology would help with the staffing issues and with comfort and wellbeing of women.

4. There are not enough gynaecology specialists to staff the existing clinics. There is a crisis in gynaecology training. Not enough people want to train in it and not enough opportunities to gain the needed experience. I don’t know any male UK graduates in Gynae training. Most say it’s because they realise they are not welcome or wanted by the patients and can’t get any experience.

Well, good; I'm glad that men are realising that they are making women uncomfortable, and therefore their presence in women's healthcare causes as many problems as it solves.

The fact that women's healthcare is struggling to recruit doctors into its specialism needs to be solved in another way than putting men in, because men can't provide the care that many gynae patients need. (In fact, I'd go as far as to say that any man who is driven to pursue a career in gynae despite knowing the female patients are uncomfortable with him is a very clear sign that that man should not be a doctor in gyn).

So we need to encourage more women into medicine and encourage more women doctors into Obs & Gyn, by making it a better and more appealing specialism (yes, that will need money spending). That is the solution, not adding men when women don't want them.

*Well, good; I'm glad that men are realising that they are making women uncomfortable, and therefore their presence in women's healthcare causes as many problems as it solves.

The fact that women's healthcare is struggling to recruit doctors into its specialism needs to be solved in another way than putting men in, because men can't provide the care that many gynae patients need. (In fact, I'd go as far as to say that any man who is driven to pursue a career in gynae despite knowing the female patients are uncomfortable with him is a very clear sign that that man should not be a doctor in gyn).

So we need to encourage more women into medicine and encourage more women doctors into Obs & Gyn, by making it a better and more appealing specialism (yes, that will need money spending). That is the solution, not adding men when women don't want them.*

Agree with all of this , 100%

I went for a smear test was very nervous have ptsd , walked in for students to be in room without being asked before I went in appointment ,could not go through with smear test I got very distressed was so shocked to see them sat there, wouldn’t mine but my history and ptsd my gp aware of. But me off re booking appointment

I've noticed they've stopped asking too

??? What???

I think you should ask, not the student, because some people e.g. like me who might want to say "no" (depending on what it is) won't feel comfortable saying "no" to the face of the individual they're saying "no" to. I'd feel mean and pressured.

I wasn't asked for permission when a student carried out, or rather failed to carry out, my colonoscopy. I only found out from reading the job title on their report. I raised the issue with the consultant in charge but they stonewalled me.

Completely agree @HeadPain. That’s a perfect (if unintended) example of what’s wrong with this process @SC215. Of course it’s hard to say no to a student directly, never mind in the open setting of a waiting room. Surely you can see that? It’s making an already stressful wait even more stressful. All I would be thinking is ‘good grief, let me just get this apt over with’, and I’d definitely be starting that apt feeling more flustered and stressed.

A medical student wouldn't be writing a report that is sent to a GP or patient. Was their job title ST (Specialty Training) or CT (Core Training) followed by a number? They aren't students, they are junior doctors. They used to be called Senior House Officers and Registrars. After 5/6 years of med school, doctors them spend a further 2 years working in a range of fields before choosing a specialism. It then takes 7+ years further training and exams to become a consultant. I hope that puts your mind at rest a little that they were a highly qualified doctor, not a medical student.

I’ve only ever had a student once and that was when I was giving birth. She was very sweet actually, probably only about 18/19. The midwife left the room and said, when PeacockPartyTime has her next contraction, feel her abdomen. The student did but whispered ‘I’ve got no idea what I’m feeling for’ 😂😂 Bless her, it was her first placement and first time in the delivery suite. Luckily I didn’t have anyone there for the actual delivery.

Thank you chesirecat99. I no longer have the report, but it said "trainee nurse" something. Nice to know they wouldn't have been a student, even if they did seem intent on pushing their camera out through my left hip. I honestly didn't know whether to be relieved or disappointed when the procedure was abandoned.

I can't say I've noticed this happing recently. When I went for my smear test 10 months ago,a student nurse was present,but I was asked beforehand if I was OK with this. The only time I've not been asked was going back quite a few years ago,when my 12 year old DD was in hospital for tests. Every time the doctor came to see her, several students would be present,and neither myself or my DD were ever asked if it was OK. After this had happened several times,I mentioned it to the doctor,who acted surprised that I 'objected'. I said I wasn't objecting to the students being present,it was the fact that I was never asked if I was alright with it!

below is guidelines from BMA is clearly states that professionals should seek consent prior to the arrival of observers if possible. Do I think it frightening and bad practice this is not happening

on-making capacity 19 10. Consent for teaching purposes

Key points
– Consent should be sought for medical students or other observers to be present during a consultation or treatment.
– Specific consent must be obtained to carry out any practical procedures on patients whilst they are anaesthetised, for training purposes.
– Doctors must obtain consent from the patient prior to a recording being made and for its subsequent use for teaching purposes.
– Consent is not required for the storage and use of material from living individuals for teaching purposes provided it is anonymised. The use of identifiable samples for teaching requires consent.
Is it necessary to seek a patient’s consent for medical students or other observers to be present during a consultation or treatment?
Yes. The doctor carrying out the consultation should explain to the patient that an observer would like to sit in on the consultation, who that person
is and why they would like to observe. Patients should feel able to say no, knowing that it will not impact on their treatment in any way.
Wherever possible, patients should be given the option of considering the request before the arrival of the observers.
Is specific consent required to teach practical procedures on a patient who has been anaesthetised?
Yes. Before any anaesthetic is given, specific consent must be obtained from the patient, to carry out any practical procedures on them for teaching purposes.
Is it necessary to seek consent from patients for the use
of visual and audio recordings of procedures, for teaching purposes?
Yes. Doctors must obtain consent from the patient prior to a recording being made and for its subsequent use for teaching purposes.
Patients may withdraw their consent to the use of visual and audio recording for teaching purposes at any time. If they do so, the recordings must be erased.
What type of consent is required for the use of human tissue for educational purposes?
Consent is not required for the storage and use of material from living individuals for teaching purposes, provided it is anonymised.

Second year student nurse here. We are trained to introduce ourselves, explain our 'role' and ask the patient if they are okay with us being present. I always say to any patients, "hello, my name is 'howtostopthinking' I am a student nurse working with the nurses here in the clinic/ward/GP practice, are you happy with me being here or would you prefer for me to not be". If there is a minor procedure that the patients need and I can do under supervision I gain consent by asking the patient again. Also when I continue to gain consent from patients, I like to let them know what my experience is in the particular procedure, for instance administering certain injections such as a subcutaneous injection as part of ward medication rounds. I have a lot of experience with that and find that patients are more at ease with more information from me. I will also be completely honest and tell a patient if I have never actually performed the particular procedure and again I gain consent.

As a patient I personally don't mind having students in my appointments, although I would probably think twice if there is a student there that I have worked with or go to Uni with but dependent on the appointment type I would probably still allow them to be there.

However, you definitely should be; A. made aware, B. have it explained who they are and why they are there, C. Be asked for consent, D. be under no obligation to have a student in your appointment. Plus they absolutely should not make you feel silly or bad for saying you would rather not have a student in your appointment or taking part of a procedure if you don't want or consent to that.