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OBJECTIVES There are recognised difficulties in teaching and assessing intimate examination skills that relate to the sensitive nature of the various examinations and the anxiety faced by novice learners. This systematic review provides a summary of the evidence for the involvement of real patients (RPs) and simulated patients (SPs) in the training of health care professionals in intimate examination skills.METHODS For the review, 'intimate examinations' included pelvic, breast, testicular and rectal examinations. Major databases were searched from the start of the database to December 2008. The synthesis of findings is integrated by narrative structured to address the main research questions, which sought to establish: the objectives of programmes involving RPs and SPs as teachers of intimate examination skills; reasons why SPs have been involved in this training; the evidence for the effectiveness of such training programmes; the evidence for measures of anxiety in students learning how to perform intimate examinations; how well issues of sexuality are addressed in the literature; any reported negative effects of involvement in teaching on the patients, and suggestions for practical strategies for involving patients in the teaching of intimate examination skills.RESULTS A total of 65 articles were included in the review. Involving patients in teaching intimate examination skills offers advantages over traditional methods of teaching. Objective evidence for the effectiveness of this method is demonstrated through improved clinical performance, reduced anxiety and positive evaluation of programmes. Practical strategies for implementing such programmes are also reported.CONCLUSIONS There is evidence of a shortterm positive impact of patient involvement in the teaching and assessment of intimate examination skills; however, evidence of longer-term impact is still limited. The influences of sexuality and anxiety related to such examinations are explored to some extent, but the psychological impact on learners and patients is not well addressed.

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This paper reports on a study that compares estimates of the reliability of a suite of workplace based assessment forms as employed to formatively assess the progress of trainee obstetricians and gynaecologists. The use of such forms of assessment is growing nationally and internationally in many specialties, but there is little research evidence on comparisons by procedure/competency and form-type across an entire specialty. Generalisability theory combined with a multilevel modelling approach is used to estimate variance components, Gcoefficients and standard errors of measurement across 13 procedures and three form-types (mini-CEX, OSATS and CbD). The main finding is that there are wide variations in the estimates of reliability across forms, and that therefore the guidance on assessment within the specialty does not always allow for enough forms per trainee to ensure that the levels of reliability of the process is adequate. There is, however, little evidence that reliability varies systematically by form-type. Methodologically, the problems of accurately estimating reliability in these contexts through the calculation of variance components and, crucially, their associated standard errors are considered. The importance of the use of appropriate methods in such calculations is emphasised, and the unavoidable limitations of research in naturalistic settings are discussed. Practice points Estimating the reliability of assessments in workplace settings is challenging, and often results in a wide-range of uncertainty with regard to such estimates. When calculating reliability via variance components methods, it is important to also include estimates of the associated standard error. Within a single specialty, different types of assessments vary widely in estimates of reliability. Formal guidance does not always allow for a sufficient number of forms to ensure adequate levels of reliability.Page 3 of 25  In clinical practice, the number of forms required to be completed by trainees to achieve reliability needs to be balanced against the practicality of creating enough opportunities to complete these assessments. Notes on contributorsMatt Homer is a researcher and teacher at the University of Leeds, working in both the Schools of Medicine and Education. His research has a quantitative focus, and within medical education relates to evaluating and improving assessment quality, standard setting and psychometrics.Zeryab Setna is a consultant obstetrician and gynaecologist at the Lady Dufferin hospital, Karachi. He has been involved in medical education for many years, both in assessment and teaching as well as in research. His main research work has been in work place based assessment, which is the subject of his MD thesis. OSCEs and equity and diversity issues in medicine. Vikram Jha is

Editor -The recent article by Barnett et al. on formal training for breaking bad news 1 raises some important issues related to advanced communication skills training and its impact on consultations. We agree that formal training may equip clinicians with some strategies with which to effectively communicate with distressed patients. However, as most clinicians will agree, breaking bad news often requires not just excellent communication skills, but also an appreciation of the patientsÕ attitudes, beliefs and verbal and non-verbal behaviours. These consultations therefore require complex interpersonal and negotiation skills and the ability to modify consultation behaviours depending on the patient and circumstances, as well as the progress of the consultation. The authorsÕ suggestion that breaking bad news requires Ôempa-thy and caringÕ is appropriate; however, these attributes come with a complex underpinning of attitudes and belief systems that are notoriously difficult to teach and assess. 2 . In addition, despite the call for a move towards a more Ôpatient-centredÕ approach to consultations, there is still a lack of convincing evidence in the patient decisionmaking literature of the effectiveness of this approach and, indeed, of suitable models that may inform interventions to promote such an approach in medicine. There is therefore a need for rigorous empirical research in order to inform the design of interventions to promote the development of advanced communication skills courses (such as breaking bad news). This research should focus on the development of valid models for appropriate consultation with patients (these may or may not be Ôpatient-centredÕ), and should identify attitudes and beliefs related to attributes such as empathy and caring that might be targeted when designing interventions. Simply relying on increasing the number or frequency of existing courses may result in institutions trying to promote appropriate doctor) patient communication based on interventions with unproven psychometric properties and ⁄ or poor practical applicability. REFERENCES1 Barnett MM, Fisher JD, Cooke H, James PR, Dale J. Breaking bad news: consultantsÕ experience, previous education and views on educational format and timing. Med Educ 2007;41:947-56. 2 Jha V, Bekker HL, Duffy SRG, Roberts TE. A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine. Med Educ 2007;41:822-9.Leeds, UK