Intended for healthcare professionals

Rapid response to:

Letters Digital rectal examination

Beyond the valley of the dolls?

BMJ 2011; 342 doi: (Published 28 June 2011) Cite this as: BMJ 2011;342:d3953

Rapid Response:

Feel the Anxiety and do it Anyway

The assertion that some doctors are reluctant to perform parts of a
clinical examination for fear of upsetting patient sensitivities is
troubling(1). Understanding the patients perspective and concerns is
important but it must go alongside ability to manage patients anxieties in
order to provide good clinical care.

As medical educators at Barts and The London School of Medicine and
Dentistry, Queen Mary University of London we recognised the problem and
openly address those aspects of clinical examination that are deemed
personal or intimate in nature.

One such example is breast examination training, where in a
clinically realistic environment, students are taught to perform breast
examination on women models. The women, who are known as Breast Training
Assistants (BTA), are trained to supplement tutor feedback with
information on student performance from the 'patient' perspective. In
small groups tutors, students and BTAs are encouraged to discuss openly
and explore practically the best approaches to breast examination.

Therefore, rather than indoctrinating undergraduate medical students
with a sense of deference towards patient sensibilities (1), and perhaps
their own sensibilities, we support them at an early stage in their
careers whilst they identify and manage their anxieties related to
personal examinations.

A failure to address the complexities of personal examinations in
undergraduate education risks perpetuating or facilitating a sense of
taboo around body parts which is inappropriate in a medical setting. This
is especially true where the student body is young and culturally diverse
and some students may have had limited contact with the opposite sex. This
aspect of education requires a sensitive approach where both the clinical
and communication components of the skill are integrated on delivery.


1. Flegg PJ. Beyond the valley of the dolls? BMJ 2011;343:d9. (2

Competing interests: No competing interests

07 July 2011
Cherry M Buckwell
Dr M Ornstein Consultant Breast Surgeon. Dr A Cushing, Mr D Lothian