Good not bad medicineBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1760 (Published 23 March 2011) Cite this as: BMJ 2011;342:d1760
All rapid responses
Des Spence and I had a brief correspondence some years ago when he
published similar views to those expressed in this piece. I am sorry that
I did not catch this article in time to respond. Methinks, despite his
useful role as resident iconoclast and fearless controversialist, he is
unwontedly dogmatic on the point or possibly, like my namesake Edsel,
suffered some early life trauma that subsequently blighted his worldview.
All new diagnostic options should be incorporated in routine practice
when validated and features of established practice jettisoned when found
lacking. We have not yet arrived at that point with bimanual or speculum
examination in primary or secondary care.
In a letter to BJOG some years ago I listed at least a couple of
dozen of my own unanticipated findings at routine bimanual or speculum
examination for smear in primary care or latterly when doing STD
The degree to which women find examination unpleasant, as reported in
papers, seems to me to reflect the nature of the question: "How much do
you dislike vaginal examination? Totally unbearable, hideous beyond
belief, scarcely bearable, ghastly, there should be a law about it or a
totally joyous, transcendent experience." I offer the thought that only
the most emancipated women would reply with any degree of positivity and
this is also seen in such public discourse as exists on the subject or its
comedic exploitation by, usually, coprolalic performers.
There is a pervasive assumption that examination is unpleasant and
that opinions at variance with this view are perverse or suspect. Is it
'proper' or 'polite' for a woman to have neutral or positive views of
genital examination - does our society permit it?
After thirty+ years I can recall barely a handful of patients who
expressed any clear enthusiasm for examination but the overwhelming
majority were entirely sanguine and accepting. Commonly I asked "Was that
OK?" or "Was that as bad as you feared?" or "would you hesitate to be
examined in the future?" and the absence of negativity was striking.
What about the role of reassurance? "Mrs. Smith your discharge is
completely normal and physiological!" "How can you tell Doctor? You
haven't looked!" Whereas I found that my immediate assessment of a
problem, even if limited in extent and certainty, was received with
When 'no touch' medicine arrives, and it will, we will achieve much
better clinical results but what about the psychological dimension? Whilst
I remain alive I will continue to look for and treasure the caring touch
and the empathy that springs from such a natural expression of
Competing interests: No competing interests