Also Human Page 12
In 1997, Terri Kapsalis, an American cultural critic and health educator, wrote the wonderfully titled Public Privates – a detailed study of how doctors are taught gynaecology3. In the book Kapsalis commented how within the canon of medical education, journal articles typically fail to discuss ‘the precarious relationship between pelvic exams and sex acts’. This supposed desexualisation becomes untenable when one learns that in the early 1970s a number of medical schools in the USA hired prostitutes as ‘patient simulators’ for their medical students to practise on. In choosing prostitutes, Kapsalis argues, medical educators inadvertently situated the pelvic examination as an act with sexual connotations.
Medical students are far from stupid, and of course they discussed the sexual potential of intimate examinations. But these discussions took place in private conversations, rather than being part of a formal teaching session. As an example, Kapsalis quotes a male physician who was told as a medical student, by his male supervisor, that ‘during your first 70 pelvic exams, the only anatomy you’ll feel is your own’4. Over a decade later, a major review of the teaching of pelvic examinations concluded that the ‘psychological impact’ on the learner was not well explored in the literature5. Little seems to have changed.
What does get discussed at great length in medical journals is the vexed issue of students practising on women who have been given a general anaesthetic prior to gynaecological surgery. Up until the early 1970s this was just how things were done, and questions weren’t raised in the literature6. In a paternalistic vein, arguments were made that women’s modesty was protected by examining them when they were unconscious. Then, with the steady increase in the number of female medical students coupled with the growth of the feminist movement, this time-honoured way of teaching students began to be called into question. The central issue was that of consent; whilst the women would have consented to a surgical procedure, and might even have agreed to have a medical student present in theatre, they were never asked to give explicit consent for medical students to undertake an intimate examination of their body that had nothing whatsoever to do with their treatment.
Since the late 1970s, this issue has been debated at great length in medical journals and, from time to time, even makes national newspaper headlines. Attitudes of the general public have clearly moved on, with recent patient surveys indicating that the overwhelming majority of women expect to be asked before medical students are allowed to practise intimate examinations on them when they have had a general anaesthetic7. But in many countries the old ways continue. For example, a survey published in 2011 of two medical schools in the UK and one in Australia found that, despite the existence in all three schools of explicit policies stressing the importance of gaining valid consent, students still found themselves in situations where they were being asked to conduct intimate examinations without consulting the patients8.
The authors of the 2011 study highlighted the conflict between, on the one hand, patient expectations and societal norms, and on the other the ‘weak ethical climate’ in the clinical workplace, where examining anaesthetised women without their explicit consent continues. Although the authors don’t unpick what’s ‘weak’ about the workplace ethics in any detail, I would argue that one of the relevant factors is the systemic denial that intimate examinations have anything whatsoever to do with sex. An example of this would be the comment following the publication of an article in the British Medical Journal about the need to gain informed consent: ‘This article is dangerous in that it isolates vaginal or rectal examinations as being intimate examinations.’9
As a patient, I have different feelings when a doctor examines my vagina or rectum than I do when they look at my hands or feet. When it comes to sex, all body parts are equal, but some body parts are more equal than others.
Similarly, in 2009 there was online fury following the publication in a Canadian medical journal of an article entitled ‘The other side of the speculum’10. In the article, medical student Brent Thoma described his discomfort when performing a vaginal examination of a patient11. Thoma was widely criticised for writing openly about his feelings, whilst other doctors criticised the journal for publishing the article in the first place. A lone voice was that of a female doctor who had this to say:
Young men and women are still sexual beings as well as medical students, yet where in the curriculum do they have the opportunity to ask about the ‘what ifs?’ of medical examinations and procedures.
The answer for many students and junior doctors would seem to be ‘nowhere’.
In a way, it’s a bit like Hans Christian Andersen’s story of the Emperor’s New Clothes. The medical profession sets out to deny that intimate examinations have anything to do with sex. And just as it took a small boy standing on the side of the crowd to voice the obvious fact that the Emperor was naked, it took a psychiatrist – someone who stood outside the specialty of obstetrics and gynaecology – to write about students’ fears of sexual arousal when examining women’s vaginas. In an unusually candid academic article, an American psychiatrist, Julius Buchwald, described how the first pelvic examination was ‘a kind of initiation rite, with clear sexual undercurrents’12. Buchwald went on to say that students’ fears of a sexual reaction to the patient tended not to be offered spontaneously. Instead, the issue was raised after other anxieties had first been voiced, and usually in response to the seminar leader asking specifically about such fears.
Buchwald was writing in the late 1970s – but it would be wrong to think that things had changed much. Just as Buchwald highlighted how medical students used jokes when uncomfortable sexual feelings were discussed, a similar observation was made in a 2014 study in Australia13. Very recently, a professor of obstetrics in London who teaches medical ethics told me that jokes are still used to mask feelings of sexual anxiety. As an example, she described a recent incident told to her in a seminar by a medical student. The (female) medical student was shadowing a male junior doctor in A & E, and she overheard him turn to his (male) colleague and say, ‘That patient needs a tube.’ In response, the student asked whether it was a bronchoscopy or endoscopy that the patient needed, and to her amazement this provoked uncontrolled laughter on the part of the two junior doctors. Eventually one turned to her and said, ‘Not tube – T.U.B.E. – Totally Unnecessary Breast Examination.’
The student was left feeling humiliated that she had needed the acronym to be spelt out, and furious that her two more senior colleagues had been eyeing up talent in the A & E waiting area. Yet she hadn’t voiced her upset until examples of professionally dubious practice were discussed in the context of the medical ethics seminar.
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Freud, in his Jokes and Their Relation to the Unconscious, was the first to explore how jokes, alongside dreams and slips of the tongue, bear the traces of repressed desire14. The whole tenor of medical training disallows explicit acknowledgement of sexual feelings on the part of the medical student or junior doctor. It’s hardly surprising, then, that such feelings often get repackaged as jokes.
In the past year or so I have talked to doctors from all sorts of different specialties. My broad conclusion hasn’t shifted: that medical education is in denial about doctors being sexual beings. Whilst a few colleagues have had training on how to cope with sexualised behaviour from patients, almost none had been part of a formal or informal discussion on what to do with their own sexual feelings. The exception to this rule was a GP colleague, who reminded me that a patient’s attraction to a doctor is quite frequently discussed in a so-called ‘Balint Group’. This GP went on to say that doctors rarely talked about their own attraction to patients in these groups, but sometimes alert group members reflected back to a colleague that it sounded as if patient–doctor sexual attraction wasn’t only happening in one direction.
Balint Groups are not new – they were started in London by two psychoanalysts, Michael and Enid Balint, in the 1950s15. In a typical Balint Group, six to twelve doctors, together with one
or two leaders, meet on a regular basis. The leaders may come from different professional backgrounds (psychoanalysts, psychologists or doctors) and will have received training in group facilitation. The purpose of the group is to help doctors explore and better understand any uncomfortable feelings they have following a consultation with a particular patient.
Discussion within the group is entirely confidential and is not recorded, summarised or reported back to anybody outside the room. The meetings tend to last between one and a half and two hours, which gives participants an opportunity to discuss an individual consultation in great depth, and one case discussion may last for forty-five minutes. There is none of the feeling of rush that pervades much of clinical training. As one participant explained16:
You leave the group relieved and renewed about your dilemma because you learn to re-examine and redefine your role with this challenging patient through the eyes and ears and hearts of your colleagues. Inevitably the issues discussed relate to other members of the group, and they too leave with added insights.
The method has now spread to over twenty-two countries across the world and doctors throughout Europe, the Americas, Australia, New Zealand, and even Russia and China, take part in these groups. Although Balint Groups were originally set up to support GPs, they are now used by different medical specialties (psychiatry, palliative care) as well as in other healthcare professions such as nursing and psychology.
The Balints introduced the metaphor of the doctor as ‘drug’; in other words, patients don’t respond only to the medications that they are prescribed; they also respond to how the doctor treats them, as people. Instead of focusing on what is medically wrong with the patient, in a Balint Group the relationship between the clinician and the patient takes centre stage. Clinicians are also asked to present a case in a particular way; they tell the ‘story’ of the patient consultation, focusing on their own feelings and the response of the patient. The clinician doesn’t have the patient’s notes in front of them, or printouts from the computer, instead they tell the story from memory. Group leaders encourage participants to bring those cases where the clinician has been left with uncomfortable feelings which linger long after the end of the consultation.
Both as a group member, and also as a co-leader, I have heard colleagues use the safety of the Balint Group to discuss potentially embarrassing sexual stuff. Once I was part of a temporary group formed over a three-day Balint training conference. The group that I was allocated to mostly consisted of Icelandic GP trainees. It was a fascinating three days; not only did these young Icelandic doctors have an exceptional use of English, but they also shed light on aspects of medical practice that I had never before heard voiced.
Many of these GP trainees were working in the small communities where they had grown up, and the cases they brought to the group highlighted the different problems that this could cause. As a young woman in your thirties, how can you best manage a consultation that starts with the patient reminding you that he remembers how cute you looked when you were still in nappies? How can you find a sexual partner in a small community when all the men you get introduced to are patients at the practice where you work? There’s only one practice in town, so if you are attracted to a patient, is it ethical to ask them to see another GP in the practice, and then begin a sexual relationship?
Balint Groups provide an ideal place to raise the full range of feelings that can arise when one person cares for another. I wondered how Peter’s career might have panned out if he had been part of a Balint Group. Maybe he would have used the group to discuss his discomfort with examining male bodies. And maybe he wouldn’t have ended up in the highly acute specialty of obstetrics, and instead could have trained as a GP a decade earlier. Unfortunately, Balint Groups are thin on the ground, and only a tiny proportion of medical students or junior doctors get to benefit from the supportive, non-judgemental space they provide.
But if a doctor can’t discuss sexual issues related to their work with their supervisors, and most don’t have the opportunity to attend a Balint Group, where else can they turn?
I suppose a medical student or doctor could take a look at the advice given by their regulatory organisation to see if it casts any light on the matter. In the UK, medical practice is regulated by the General Medical Council (GMC), but guidelines published by this organisation wouldn’t take you very far17. This becomes clear when you compare what the GMC has to say about sexual boundaries with the Medical Council of New Zealand’s advice on the same issue18. Both sets of guidelines kick off in a similar vein. The GMC document published in 2013 states that:
Trust is the foundation of the doctor–patient partnership. Patients should be able to trust that their doctor will behave professionally towards them during consultations and not see them as a potential sexual partner.
Parallel guidance from New Zealand published a few years earlier is:
The Council rejects the view that changing social standards require a less stringent approach. Only the highest standard is acceptable and the professional doctor–patient relationship must be one of absolute confidence and trust.
Not much difference there, with both professional bodies emphasising the centrality of trust. But the New Zealand guidelines also include a couple of simple, insightful statements:
It is important to remember that doctors and patients have the same emotions and feelings as any other people. It is not uncommon for two people who meet in a professional setting to feel attracted to each other.
Judgement on your behaviour is not based on the attraction you feel towards a patient but how you respond to this attraction.
At no point in the GMC document is the possibility raised that a doctor could feel attracted to a patient – and that they won’t be judged for their feelings, but for their response in relation to the attraction. This omission becomes all the more surprising when you see how the GMC has failed to incorporate the findings of a national research project on sexual boundary violations in healthcare19. And what makes it even more extraordinary is that the research project was commissioned by the Council for Healthcare Regulatory Excellence (CHRE), an umbrella organisation that oversees the work of the GMC as well as eight other healthcare regulatory bodies (nurses, pharmacists, etc.).
In 2008 the CHRE published a set of three documents: a clear statement on the responsibilities of healthcare professionals; an extensive literature review; and a series of recommendations on how best to train professionals in order to minimise boundary violations. This work was commissioned by the Department of Health in response to a series of inquiries into serious breaches of sexual boundaries by healthcare professionals. It was carried out in consultation with patient groups, professional bodies and health profession regulators including the General Medical Council. In the published documents, the possibility that a practitioner could be attracted to a patient is made explicit:
If a healthcare professional is sexually attracted to a patient and is concerned that it may affect their professional relationship, they should ask for help and advice from a colleague or appropriate professional body, in order to decide on the most professional course of action to take.
If a healthcare professional is asked for advice by a colleague who feels attracted to a patient or carer but has not acted inappropriately, they do not have a professional duty to inform anyone.
Students must be taught that there is nothing unusual or abnormal about having sexualised feelings towards certain patients, but that failing to identify these feelings and acting on them is likely to result in serious consequences for their patients and themselves
All three reports were published before the GMC wrote its current statements about sexual boundaries. But the GMC’s guidelines (unlike those of its Antipodean counterpart) contain no mention of the possibility that a doctor could ever feel attracted to a patient. In UK medicine at least, it seems as if doctors are not allowed to have sexual feelings towards those they treat, ever. Despite the fact tha
t a national research project concluded that brushing these issues under the carpet increases the risk of sexual boundaries being breached, the topic is written out of the guidelines. So much for evidence-based medical education.
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Shortly after setting up the Careers Unit, a doctor requested an urgent appointment. Whilst he told me in the session that he had failed to complete his GP training, he omitted to say that he was being investigated by the GMC, following the death of a patient, and that he had significant conditions attached to his licence to practise. After this experience, we routinely checked every doctor’s listing on the open access GMC register, prior to their first appointment.
On a number of occasions I have seen doctors whose registration with the GMC was subject to the following conditions:
Except in life-threatening emergencies, you must not carry out consultations with female patients, without a chaperone present.
You must keep a log detailing every case where you have carried out a consultation with such a patient, which must be signed by the chaperone.
You must keep a log detailing every case where you have carried out a consultation with such a patient in a life-threatening emergency, without a chaperone present.
Typically doctors who have these sorts of conditions attached to their registration have been subject to a complaint from one or more female patients that they have been examined inappropriately. If the police are involved, and the doctor finds themselves charged with a sexual offence, even an acquittal in court won’t necessarily protect them from having conditions placed on their registration. In court, the jury is instructed to apply the criminal standard of proof, that the prosecution has established the doctor’s guilt ‘beyond all reasonable doubt’. But in a Fitness to Practise tribunal, the panel has to apply the less stringent civil standard, namely, that ‘on the balance of probabilities’ the account of the patient was preferred over the account of the doctor. This crucial difference between ‘beyond all reasonable doubt’ and ‘on the balance of probabilities’ can sound the death knell to a doctor’s medical career.