[posted as supplied by author]
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Guidelines to medical students about proper conduct with regard to physical examination of patients who are under the age of 18 years old (minors)
Definitions
1. These guidelines are to be read in conjunction with the Guidelines to medical students about proper conduct with regard to physical examination of adult patients which will be referred to in this document as: the adult guidelines.
2. The terms child, children, and child patient(s), will be used to refer to any patient, or patients, under the age of 18 years.
3. The term valid consent refers to consent that is explicitly expressed and meets the legal criteria for consent, i.e. that it is informed, that the person giving consent is competent (has legal capacity) to give consent, and that the consent is given voluntarily. Consent is valid only if it is given by a person who has the legal power to give consent (see paragraphs 11 and 12). Valid consent may be given orally and need not always be written consent (but see paragraphs 13 and 14).
4. The term parent will be used to refer to any person who has parental responsibility for the child in question (see paragraph 12).
5. The term Gillick competent child refers to a child aged under 16 years old who has "reached sufficient understanding and intelligence to enable them to understand fully what is proposed". This definition is taken from the judgement in the Gillick case.
Background
6. These guidelines outline the general approach that medical students should take to the examination of children.
7. The general points of the adult guidelines are equally relevant to the examination of children (see appendix 1). Students should be sensitive to the fact that it is as important to respect the privacy of children as it is of adults. Students should introduce themselves to both the patient (if of an age to understand) and his/her parent(s). The nature of the examination should be explained, and students should ensure that, throughout the examination, the patient is happy for the examination to continue.
8. The examination undertaken should have a clear educational purpose, which should be explained to the person(s) giving consent.
9. The person(s) who give consent for the examination must understand that the purpose of the examination is for student training and is not generally part of the clinical care of the patient. Medical student examination may, on occasions, form part of the clinical care, supervised by a trained doctor. On these occasions it should be explained that the examination will be supervised in detail.
10. It must be clear to both the child (if of sufficient understanding) and to the parent that clinical care will not be affected by refusal of consent to examination by a student.
Outline of Legal Position With Regard to Consent and Minors
11. The touching of patients without valid consent is potentially battery. The legal position with regard to children is complex. If the child is competent and gives consent then such consent is normally valid. Alternatively a person with "parental responsibility" (see paragraph 12) can give consent. The broad position therefore in English law with regard to the examination of patients under the age of 18 years is that such examination would not constitute battery if valid consent for the examination has been given either by a person with parental responsibility or by the child, if competent. The general presumption is that a child aged 16 or 17 years old is competent to give such consent, unless there are grounds for doubting this. In the case of children aged less than 16 years, there is common law provision for such children to give consent as long as they are "Gillick competent" (see paragraph 5). As can be seen, the criterion for establishing Gillick competence is not well specified. Competent minors can, therefore, give consent to treatment that is in their best interests. The legal situation with regard to competent minors who are refusing treatment that is in their best interests is not clear. A competent adult (i.e. aged 18 years and over) can refuse any, even life-saving, treatment, and a doctor who imposed treatment in these circumstances would be liable in battery. This is not necessarily the case with regard to patients under 18 years, and a doctor who allowed a patient less than 18 years old to come to harm on the grounds that the patient was competently refusing treatment might be found liable in negligence.
12. The legal concept of "parental responsibility" is key to understanding who is able to give consent for a child to have a physical medical examination. This can be a complex issue. The child’s mother will, almost always, have parental responsibility, as will the child’s father if married to the mother. Biological fathers whose names appear on the birth certificate will automatically have parental responsibility. Other unmarried fathers may acquire parental responsibility through a formal process. Grandparents and step-parents would not normally have parental responsibility (although under some circumstances they can acquire it).
Guidelines
13. A child should only be examined by a medical student with the valid consent of at least one parent or with the consent of the child if aged 16 or 17 years and competent (see paragraphs 11 and 12; and paragraph 14 for exceptions). If the parent is present at the time of the examination then the consent can be obtained at that point by the student. If the parent is not available at the time then a medical student should only examine the patient if a parent has given prior valid consent. The medical student should establish from a relevant authority (medical or nursing staff, or from the medical and nursing notes) that such prior consent has been given. If there is doubt as to whether the parent is competent to give valid consent, or if the student becomes aware of a difference in view between parents, students should seek advice from a doctor of at least senior house officer grade or the nurse who is clinically in charge. Medical students should not carry out an examination on a child patient without such parental consent, even if the child’s immediate carer (such as a grandparent or child minder) gives "consent". The fact that consent has been obtained, and from whom, should be recorded in the notes.
14. A child aged less than 16 who is also "Gillick competent" (see paragraph 5)cangive consent for examination by a medical student. Such a situation could arise if the child has come under medical care unaccompanied by the child’s parents (e.g. a student from a boarding school). In such circumstances, a medical student should only examine the child if a responsible doctor (of at least senior house officer grade), or the nurse who is clinically in charge, has obtained valid consent from the child for such an examination. Such valid consent would require the health professional to be satisfied that the child is Gillick competent. The health professional should state (and sign) in the clinical notes that the child is competent to give consent. The health professional must also believe it is an appropriate time for the student to examine the child.
15. On occasions a parent may have given valid consent for the child to be examined
by a medical student, but the child may make it clear that he/she does not wish to be examined. In such circumstances medical students should not proceed with examination. Conversely, a competent child may give permission for medical student examination but one or more parents may refuse such examination. In such circumstances the medical student should not proceed with examination.
16. In some teaching situations it is desirable for a number of students to examine a child, for example on a teaching ward round when the child demonstrates an important physical sign. If a parent is not available at that time to give consent, then such examination can only be carried out if prior valid consent has been given, including consent that the child is examined by more than one student. The doctor who is carrying out the teaching should be sensitive to the child's feelings (e.g. of embarrassment) and be prepared to adapt or terminate the teaching session as appropriate.
17. Medical students should not examine any child patient less than 16 years old (or if the patient is incompetent, less than 18 years old) without at least one other person being present. In most situations a medical student can examine a child patient if at least one of the child’s parents or a qualified health professional is present (but see paragraphs 18-22 for special situations). Some adolescents may prefer to be examined without their parents present. Students should be sensitive to this possibility and should normally ask the child their preference. If the child does not want a parent present then a qualified health professional should be present. The examination should not be carried out if either the parents or the child are not happy with the arrangements.
18. In the case of a female child patient aged 10 years or over a male medical student is strongly advised to carry out an examination only if a qualified health professional or female medical student is present, as chaperon, even if a parent is present.
19. Female medical students may sometimes prefer to have a chaperon present, in addition to a parent, when examining male teenagers.
20. Medical students should never carry out either rectal or vaginal examinations on a child (i.e. a person under 18 years old).
21. With regard to the examinationof children under anaesthetic, the adult guidelines apply (see appendix 2). In the case of children under 16 years old valid consent should involve the parents, and in the case of Gillick competent children, the child as well. Rectal and vaginal examination should not be carried out on children (i.e. a person under 18 years old, see paragraph 20).
22. In the case of child patients in whom the question of child abuse has been raised, students should only examine the child under guidance from, and in the presence of, a senior doctor involved in the care of the child.
Implications of These Recommendations for Teachers of
Medical Students
23. All those who teach medical students, where such teaching involves students seeing patients less than 18 years old, should follow these guidelines and the adult guidelines.
24. At the core of these guidelines is the requirement that valid consent procedures are followed. This involves obtaining, in most circumstances, valid consent from a parent even if the parent is not present at the time that the student examines the patient.
25. A student should not be asked to examine a patient unless valid consent, as outlined in these guidelines, has been given.
26. Students should not carry out rectal or vaginal examinations on patients under aged 18 years, even with consent (indeed, consent should not be sought for such
examinations). (See paragraphs 20-21).
27. Those carrying out teaching should be sensitive to the child’s feelings (e.g. of embarrassment) and be prepared to terminate the teaching session as appropriate (see paragraph 16).
28. Students may need to ask doctors, or the nurse clinically in charge, to assess the
competence of children to give consent to examination (see paragraphs 14).
Implications of These Recommendations for Units Involved in Teaching Medical
Students
29. It is recommended that parents (and children if competent to give consent to
examination) should be given information on admission to the ward or in outpatients, to the effect that their child is being cared for in a teaching environment and that medical students may be present at any stage during the health care as part of student training. Parents should be further informed that they may decline student involvement at any stage without affecting clinical care.
30. It is recommended that a procedure is put in place for asking parents if a medical student may examine their child in those situations where such an examination may be appropriate at a time when the parents are not present. It is important that parents understand both the nature of the examination(s) and that the purpose is for student training and is not part of the clinical care of the patient. It is also important that parents understand that they may decline consent and that the clinical care of their child will not be affected if they do so.
Committee Members
These guidelines have been produced by the Chaperon Committee of the JCC Committee:
Tony Hope (Chairman)
Peggy Frith (Deputy Director of Clinical Studies)
Janet Craze (Consultant in Paediatrics)
Francis Mussai (5th Year Medical Student)
Ambika Chadha (6th Year Medical Student)
Acknowledgements
The Committee would like to thank the following for their helpful advice and/or comments on earlier drafts of this report:
Dr Brian Angus, Clinical Tutor in Medicine, Honorary Consultant Physician, University of Oxford;
Dr Malcolm Benson (Chairman) of the Hospital Ethics Committee of the Oxford Radcliffe Hospitals Trust;
Dame Fiona Caldicott, Principal, Somerville College, Oxford;
Professor Alastair Campbell, Centre for Ethics in Medicine, University of Bristol;
Miss Jane Clarke, Consultant Surgeon, Department of Surgery, John Radcliffe Hospital, Oxford;
Dr G. Greveson, Convenor of Clinical Skills, University of Newcastle Faculty of Medicine;
Judith Hendrick, Solicitor and Senior Lecturer in Law, Oxford Brookes University;
Dr David Jones, Consultant Psychiatrist, Park Hospital for Children, Oxford;
Mary Judge, lay member and Vice-Chair of the Hospital Ethics Committee of the Oxford Radcliffe Hospitals Trust;
Mr Stephen Kennedy, Clinical Reader in Obstetrics and Gynaecology, University of Oxford;
Penny King, lay member of the Hospitals Ethics Committee of the Oxford Radcliffe Hospitals Trust;
Dr Tim Lancaster, Director of Clinical Studies, Oxford University Medical School;
Mr Ian Mackenzie, Reader in Obstetrics and Gynaecology, University of Oxford;
Dr James Morris, Medical Director, Oxford Radcliffe Hospitals Trust;
Sally Newman, Head of Legal Services, Oxford Radcliffe Hospital Trust;
Dr Gerard Panting, Medical Protection Society;
Dr Jonathan Roberts, GMC Standards, The General Medical Council, London;
Dr P K Schutte, Deputy Head of Advisory Service, The Medical Defence Union;
Dr Anne Stewart, Consultant Adolescent Psychiatrist, Oxfordshire Mental Healthcare NHS Trust;
Professor Rajesh Thakker, Examiner in Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford;
Jean Ware-Morphy, lay member of the Hospital Ethics Committee of the Oxford Radcliffe Hospitals Trust.
Professor Andrew Wilkinson, Head, Neonatal Unit, John Radcliffe Hospital, Oxford;
The Committee would also like to thank Zena Gibbs for her administrative support.
[posted as supplied by author]
Guidelines to medical students about proper conduct with regard to physical examination
of adult patients
These guidelines are relevant to students’ examination of adult patients and aim to help them avoid allegations of assault, misunderstandings and embarrassment throughout their clinical training.
Recommendations with regard to the examination of child patients will be the subject of separate guidelines.
Guidelines
A. General Points
- Students should always ensure that patients are aware that they are medical students and not doctors. Students should wear clear identity badges prominently displayed at all times. Such badges should state "medical student" in letters sufficiently large to be readable by most patients. Students should introduce themselves as a student.
- Students should have permission from a qualified doctor or nurse before approaching a patient with a view to carrying out a medical examination.
- Students should explain to the patient, in a way the patient can understand, what the examination involves and the reasons for it; and give the patient an opportunity to ask questions. If the examination is purely for an educational purpose this should be made clear to the patient. The patient should also be reassured that refusal will not affect their treatment.
- Students should be sensitive to patients’ feelings, and preserve patients’ modesty.
- Students should enable maximum patient privacy. In outpatient settings patients should be enabled to undress and dress in privacy and a clear explanation should be given as to what garments should be removed. Students should minimise patient exposure and provide covering for exposed parts of the body when not being examined. When exposure is necessary in order for the examination to be properly carried out this should be explained.
- Students should adopt a professional approach and avoid personal comments about patients, for example about their body shape or attractiveness or clothing. Terms of endearment such as "pet", "dear", "love" should be avoided.
- Patients have a legal right to refuse to allow medical students (or indeed health professionals) to carry out a physical examination.
B. The use of chaperons
- For the purposes of these recommendations a chaperon is a third person (i.e. additional to the patient and to the student carrying out the examination) who is of the same sex as the patient and is either a medical student or a health professional. A relative of the patient is not a chaperon for the purposes of these recommendations.
- A chaperon is different from a companion for the patient. Patients will sometimes want a friend or relative (companion) present during history taking and examination. In such circumstances the patient’s wishes should be respected. In unusual circumstances the student may think that it is not appropriate for the companion to be present, in which case s/he should discuss this with a qualified member of the clinical team (normally one of the doctors). One purpose for the presence of a chaperon is for the protection of the student against false allegations of unprofessional behaviour and it is not appropriate for the patient’s companion to fulfil this role.
- If a chaperon is present students are advised to make a note of the chaperon’s name at the appropriate place in the medical notes.
- If a patient wishes to have a chaperon present and there is not one available then the examination should not be carried out.
- If the student feels unhappy in carrying out an examination without the presence of a chaperon then it is advisable for the student to postpone the examination until a chaperon is present.
- If during the course of an examination the patient says something, or behaves in a way that either suggests that the patient is unhappy for the examination to continue, or might be making a sexual advance, or might become violent, the student is advised to stop the examination and seek advice from a relevant health professional as to what to do.
- In several situations (see below) patients should be offered a chaperon. This is best done by considering it routine and by using a matter of fact manner. Thus the student might say to the patient (before carrying out the examination): "I now need to carry out a rectal examination (explain if necessary). Before I do this would you like a chaperon to be present?" Or, (after explanation of the examination to be carried out), "It is the policy for patients to be offered to have a chaperon present whilst such an examination is carried out by a medical student. Would you like me to find a chaperon?" If the patient may not be familiar with the term "chaperon" it may be preferable to say something like: "We usually ask another member of staff to be present during this examination. Would you like me to find someone?"
- If a patient does not want a chaperon then the student should not impose one. However there are situations (described below and above, para 13) when the student should not proceed without a chaperon. In such situations the student should not undertake the examination.
- Vaginal examination. Students should not carry out vaginal examination without a doctor, nurse or midwife present. The Royal College of Obstetricians and Gynaecologists recommends that a female chaperon should be offered to all women undergoing vaginal examination, and this practice should be followed by students as well. However, if either the student, or health professional present is female, it would not normally be necessary to have an additional person present at the examination.
- Rectal examination (both male and female) and female breast examination. All patients should be offered the possibility of having a chaperon present. Male students are advised to have a chaperon present when carrying out either of these examinations with female patients.
- Male genitalia. All patients should be offered the possibility of having a chaperon present before testicular or scrotal examination is carried out including examination for inguinal hernia and hydrocoele. Female students may sometimes prefer to have a chaperon present even if the patient himself does not mind.
- Female chest examination. Examination of the cardiovascular system and of the respiratory system of female patients normally requires touching (although not examination of) the breast. It is important that students, of either sex, explain the procedure and ensure that the patient is willing for the examination to be undertaken. Students should also be sensitive to potential embarrassment. It is not normally necessary to specifically offer that a chaperon be present before conducting such examination. However, male students may sometimes prefer to have a chaperon present.
C. Examination of anaesthetised patients
- When patients give consent for an anaesthetic and operation they need to be told what the operation involves. If they are not so told then the operation is potentially battery (i.e. illegal). It seems a reasonable interpretation of the legal position that the standard consent to the operation would cover consent for a medical student to take an active part in the operation (such as holding a retractor). However, the general consent for the operation is unlikely, from a legal point of view, to cover examination of the patient for students’ own education. Battery is defined as any touching without consent. If a medical student, therefore, examines a patient (such as feeling a lump in the patient’s abdomen) when the patient is anaesthetised, and when this is not part of the operative procedure, then, from a legal point of view, this would probably constitute battery. It is therefore recommended that any physical examination by a student on an anaesthetised patient where this is for student education (and not part of the operative procedure) should be undertaken only with the patient’s prior valid consent which should be obtained by a doctor. Students should refuse to carry out an examination when they do not believe that consent has been given.
- Vaginal, rectal and female breast examination with anaesthetised patients. It is recommended that these examinations should be carried out on anaesthetised patients only with explicit valid written consent from patients. Such consent should be obtained by a doctor and not by a student. It would not normally be appropriate for patients to be asked to give such consent where such examination is not relevant to the operation which they are undergoing.
- The implications of these recommendations for health professionals involved in the education of medical students and for the medical school
- Qualified staff should ensure that students are introduced to patients. Staff should be clear and honest with patients and inform patients that the students are "medical students". Students should not be introduced as colleagues or as doctors. Name badges should display the name and status (i.e. medical student) clearly and in sufficiently large font to be readable by most patients.
- Medical students may ask a doctor, nurse or other health professional to act as chaperon when examining patients (the likely situations, and advice to students, are outlined above). If students are to be properly trained it will be necessary for them on occasions to make such requests. The Medical School realises staff are very busy and that urgent clinical duties must take precedence over helping student education. The Medical School is grateful to all staff who are able to act as chaperon.
- The points under section C (examination of anaesthetised patients – paragraphs 20 and 21) are relevant to those involved in teaching students in the presence of anaesthetised patients. Students should not be asked to undertake examination of an anaesthetised patient without explicit consent where such examination is for student education, and is not part of the operative procedure. Explicit consent should be obtained by a doctor, and not by a student. GMC recommendations (December 2001) to doctors regarding intimate examinations state: "If you are supervising students you should ensure that valid consent has been obtained before they carry out any intimate examination under anaesthesia".
- Patients should be informed that medical students may be present at any stage during their health care as part of student training. Patients should be further informed that they may decline student involvement at any stage. The Committee recommends that a statement to this effect should be included in letters inviting patients to attend an appointment.
- It is recommended that students learn how to carry out genital and rectal examinations using a mannequin before carrying out such examinations on patients.
Committee Members
These guidelines have been produced by the Chaperon Committee of the JCC Committee:
Tony Hope (Chairman)
Peggy Frith (Deputy Director of Clinical Studies)
Douglas Noble (6th Year Medical Student)
Ambika Chadha (5th Year Medical Student)