The report into obstetrics practice at the maternity unit of Our Lady of Lourdes Hospital in Drogheda by Judge Maureen Harding Clark was utterly damning. As a health professional, I found it a sad and difficult read; what it must have been like for the women directly affected, and their families, can only be imagined.
"The most common complaint we heard from patients was how doctors carried out procedures on them without discussion beforehand. Very little was explained. We heard the same comment from so many patients that we have included recommendations in how to deal with poor communication skills."
So wrote Judge Harding Clark in a section of the report dealing with the interviews she had with former patients of Dr Neary, the disgraced obstetrician. Rather than primarily expressing hurt or anger at the unnecessary loss of their wombs because of the high rate of Caesarean hysterectomy, it is the lack of explanation and communication by doctors that rankled most with the women.
This is a serious finding. It has implications that go well beyond the Drogheda hospital. It has ramifications for the undergraduate and post- graduate training of doctors and it suggests the ongoing assessment of doctors' competence must include an analysis of their communication skills as much as their clinical acumen.
In fairness, it must be pointed out that medical schools here have made great strides in the area of communication skills training. All now offer dedicated modules, including the use of actors and video analysis of consultations, to develop the student doctor's ability to communicate well. The postgraduate continuing medical education scheme of the Irish College of General Practitioners contains modules on consultation analysis during which family doctors review and critique each other's performance.
Yet the conclusion in the report suggests more needs to be done. And specifically, it calls for better explanation of medical procedures before they are carried out, which brings us to the area of informed consent.
Defined as the process whereby a healthcare professional discloses necessary information to a patient prior to obtaining consent to go ahead with a procedure, the principal purpose of informed consent is to ensure that sufficient information has been provided to the patient prior to giving consent to medical treatment or examination.
Evidence that informed consent is not always sought comes from a 2003 paper in the British Medical Journal: The ethics of intimate examination - teaching tomorrow's doctors. The survey of almost 400 medical students attending a medical school in Britain looked at their experience of carrying out vaginal and rectal examinations.
While just 5 per cent of intimate examinations reported by senior medical students were done without explicit consent, in a third of examinations by second year students, no consent was obtained. But perhaps the most alarming finding was that 24 per cent of some 702 intimate examinations carried out on sedated or anaesthetised patients were performed without either written or oral consent. In many instances, more than one student examined the same anaesthetised patient.
Asked for their comments on this practice, many of the students expressed disquiet but said they felt compelled to perform the examination. The comment of one fourth year student was particularly worrying: "I was told in the second year that the best way to learn to do rectal examinations was when the patient was under general anaesthetic. That way they would never know."
Ethical values are changing: what once may have seemed acceptable must now be prevented. Traditional teaching of intimate examinations - which a student clearly must be able to perform before he qualifies - was guided by the utilitarian ethic that learning how to do intimate examinations would benefit other patients. Now the Kantian ethic, which rejects using one person as a "means to an end", holds sway.
Of course, there are now alternative teaching methods. Skills can initially be acquired using mannequins. In the US and Australia, trainee doctors are taught intimate examination techniques using non-patient volunteers.
But the fundamental key is to respect the patient. It is the patient's right to decline examination by a student or a doctor. Before a patient enters the consultation room, he should be asked whether a student may be present. Before the student carries out an examination, the patient should again be asked permission, with the question phrased in a way that allows the patient to decline without fear that his subsequent care will be compromised. The person, irrespective of age or gender, should be offered a chaperone. And medical students should never carry out the intimate examination of a child.
Patients, too, have a role to play in helping doctors communicate better. By asking questions you are more likely to jog a healthcare professional's memory than cause offence.
mhouston@irish-times.ie
Dr Muiris Houston is pleased to hear from readers, but regrets he cannot answer individual queries.
MEDICAL MATTERS
Muiris Houston