Views of Foundation Doctors (year 2) on distress likely with genital examination in children.

Little is known about the attitude of newly qualified doctors towards intimate examination of children. During the 2 course of a training day in child protection, an exercise was undertaken to ask Foundation doctors (FY2) what impact they thought genitalia examination had on children. These responses have been compared with the only systematic examination of the response of children and their parents to such examinations that has been published. The doctors in question believe such examinations to be more distressing than children or their parents appear to perceive. It is likely that such perceptions may inhibit newly qualified in efforts to acquire such skills that may not have been acquired as medical students. This may be an area of continuing difficulty for the future because of the changes in access to relevant learning experiences for medical students.

INTRODUCTION

The ethics of learning intimate examination by medical students and junior doctors has been a topic of discussion in recent years. Both ethical 1and legal 2 considerations have reduced some of the traditional opportunities to learn such examinations. There have been various efforts made to replace traditional approaches, ranging from simulators 3to patient or volunteers acting as teachers 1.

Little attention has been paid to the impact of this change on doctors’ attitudes to examination of the genitalia of pre-pubertal children and there is relatively little information about children's views on genitalia examination nor on that of junior doctors.

METHODS

In the United Kingdom (including Northern Ireland) newly qualified doctors are enrolled for two years in a generic skills training rotation referred to as Foundation Training. Various arrangements have been made for formal training activities in different regions of the UK. In Northern Ireland all such Foundation Trainee Doctors have to attend eight mandatory training days and one of these is devoted to child protection.

During one such session the Foundation Doctors were asked about their opinions on what young children would feel about examination of the external genitalia. 41doctors attended this session, one of seven sessions on the topic of child protection for the cohort of 235 doctors in their 2nd year of foundation training in 2010/2011.

The information about children’s’ views were taken from a study involving Norwegian children and their parents in 2007 4. For this study the authors devised two scales, which were published in English translation in the original article. - Children's were asked to indicate on a ‘smiley faces’ scale (Fig 1) what they felt about the experience of examination. Parents were asked for their observations as to the degree of anxiety / restlessness on a scale ranging from ‘none’ to ‘a whole lot’.

Fig 1

Faces Rating Scale

During the course of the session on Child Sexual Abuse the Foundation Doctors were asked to indicate on the same scales how they believed children would describe their experiences and how parents felt their children reacted during the examination.

Statistical Analysis was undertaken using WINPEPI. 5 Effect size was also calculated using WINPEPI.

RESULTS

The data are presented in three ways: as scores and 95% confidence intervals; differences between groups were analysed by chi-squared analysis and effect sizes were calculated to summarise the size of the differences between groups

SCORES AND 95% CONFIDENCE INTERVALS

The results are summarised in Tables 1 and 2. For ease of comparison the 95% confidence intervals for the comparisons are presented graphically in Figs 2 and 3.

Table 1

Perception of Examination of Genitalia - Comparison of perceptions of Children examined with opinions of Foundation Doctor's (FY2)

	FY2 Doctors	Children
Category- Perception of Examination of Genitalia	Number	Proportion	95% Confidence Interval for Proportion		Proportion	95% Confidence Interval for Proportion
Positive	0/37	0*	0.000 to 0.078	77	0.49*	0.410 to 0.565
Somewhat Positive	0/37	0*	0.000 to 0.078	35	0.219*	0.162 to 0.291
Neutral	14/37	0.3784*	0.234 to 0.541	34	0.213*	0.156 to 0.284
Somewhat negative	15/37	0.4054*	0.257 to 0.568	7	0.045*	0.020 to 0.086
Somewhat negative	15/37	0.4054*	0.257 to 0.568	5	0.032*	0.012 to 0.069

Table 2

Perception of Stress produced - Comparison of perceptions of Parents examined with opinions of Foundation Doctor's (FY2)

	FY2 Doctors	Parents
Category Perception of Stress of Examination	Number	Proportion	95% Confidence Interval for Proportion	Parents (No)	Parents (% of 158)	95% Confidence Interval for Proportion
None	2	0.0571*	0.010 to 0.176	105	0.664*	0.588 to 0.735
Little	17	0.4857*	0.325 to 0.649	48	0.303*	0.235 to 0.379
Some	12	0.3429*	0.201 to 0.510	4	0.026*	0.008 to 0.060
Alot	2	0.0571*	0.010 to 0.176	1	0.007*	0.000 to 0.031
A Whole Lot	2	0.0571*	0.010 to 0.176	0	0*	0.000 to 0.019

Fig 2

Comparison between FY2 doctors perception and children's perception of examination of genitalia.

Fig 3

Comparison between FY2 doctors perception and parents perception of examination of genitalia.

CHI SQUARED ANALYSIS

As indicated in Tables 1 and 2, the difference between children’s’ views and doctors opinions was statistically significant as was the differences between parents opinions and doctors opinions.

Effect Size

The effect sizes for the difference between Children and FY2 doctors perceptions was calculated as Cohen's w = 0.68 (corrected for table size = 1.316). By Cohen's criteria 6 this is a large effect size. The effect size for the difference between FY2 doctors and parents was calculated as Cohen's w = 0.604 (corrected for table size = 1.073). By Cohen's criteria this also is a large effect size.

DISCUSSION

These findings suggest a significant gap between the views of children about intimate examination and the views of junior doctors, with junior doctors anticipating it will be experienced as producing more anxiety than it does produce. This discrepancy may result from a natural reluctance about intrusion into a private domain, a reluctance that may only be overcome with experience.

However it may also represent one of the consequences of the apparently restricted access to learning such examinations that may be the case in recent years. The study guide provided by the medical school which the vast majority of the doctors had attended defined intimate examinations as involving ‘breast, external and internal female genitalia, penis, scrotum and rectum’ and also says that such examination is ‘Not appropriate’ in Minor(s) (aged <18years) who are conscious and Gillick incompetent’ and that “Students are always at liberty to refuse to examine a patient for educational purposes”. 7These findings parallel the findings about limited knowledge of anatomy of the genital area described for colleagues of this group in preceding years.8

The existence of such an area about which doctors are not knowledgeable and are reluctant may be one of the factors producing a reluctance about engaging with child protection matters in general, for example by inducing a fear of stumbling across an area of which the individual doctor has little knowledge or experience. At the same time the limitations of the evidence needs to be recognised — the sample of children from whom the above values are taken were a small percentage of those approached, although the study in question has been described as “good science” 9

It may also be that attitudes to such examinations are different in the Norwegian population from which the original data comes. There is good evidence for different response styles (i.e. tendency to use the extremes or the middle values of a scale) in different cultures. 10 Children and adults may also have different response styles with young children tending to use the extremes more than older people. 11 However the distribution of results does not suggest that differing response styles are responsible for the differences described. For example there is no evidence of such clustering of the distributions of answers in Figs 2 & 3.

The determinants of a patient's anxiety about a particular type of examination is likely to be related to characteristics of the examiner as well as that of the examinee 12. It is possible that an unwarranted anticipation of anxiety may produce reluctance on the part of the examiner that will in turn make the examinee more anxious. Since the attitude of the parent is also likely to be one of the determinants of the child's response to such examination there is likely to be a group of interacting factors relevant. A review of the presence of parents during painful procedures suggests that their presence does not have any clear-cut advantage but there is no evidence to suggest it causes extra difficulties.13 The factor that is most amenable to change is probably that of the doctor and the need to help doctors acquire attitudes which minimise patients discomfort with examination is likely to be a valuable contribution to doctors training, helping them overcome their fear that they “might break one”.14