An Intimate Exam

A pelvic exam can be an uncomfortable experience, not just for the patient but also for the person doing the procedure, especially if that person is a medical student who has never performed an intimate exam on a real-life woman.

To prepare doctors-to-be for their first time in an exam room with a woman whose feet are in stirrups, medical schools often bring in paid patients who tell the students if something hurts and, in some instances, instruct students on how to perform the exam.

That was just what the University of Minnesota Medical School did until this spring, when a group of faculty members and administrators chose to replace living, breathing patients with tabletop anatomical models.

“We looked at the cost-benefit ratio and didn’t think it was worth it,” said Sharon Allen, a professor of family medicine and community health who is course director of “Physician and Patient,” the class where students get their first chance to interview and examine patients.

Under the old curriculum model, students performed one pelvic exam on a patient but didn’t do their second exam for another six months to a year, once they were in a third year obstetrics and gynecology clerkship. “They were doing this procedure once, as more of a comfort and exposure type of experience, but not really learning the skill until their clerkship.” Students now work with the plastic models and observe a faculty member performing the procedure on a patient.

Though the change will probably save at least a few thousand dollars, Linda Perkowski, associate dean for curriculum and evaluation, said the decision wasn’t purely a financial one. “Money is important but we would never decide something just based on money.” Over all, the medical school spends $150,000 annually to train and pay standardized patients for various procedures.

But those who got to perform the procedure on patients as second-year students worry that the students who follow them will miss out on a valuable experience.

Patty Dickmann, who is president of Minnesota’s fourth year class, said the change is “unfortunate.” Having the firsthand experience of examining a practice patient “significantly reduced the level of stress when performing my first pap smear” during her OB-GYN clerkship.

Another fourth year, John Thomas Egan, said he and his classmates consider the practice exam “an important learning tool, taking students who perhaps may never have been involved with any sort of intimate exam or touch and giving them this experience in a very safe space.”

The initial one-on-one interaction with a patient who’s comfortable with her body is helpful in calming nerves and building confidence, Egan added. “As a guy, at least, there’s a certain amount of anxiety” about conducting a pelvic exam, Egan said, but having a first experience with a woman who has chosen to be a model for medical students “gives you a certain level of comfort.” When he did the exam as a second-year student, “the patient gave me all sorts of feedback and was really, really helpful.”

Other medical students voiced their concern to the campus newspaper, the Minnesota Daily. On Thursday, the paper published a letter from a non-medical student who said the curriculum change upset her as a patient. “In an era where women’s bodies are continually objectified and encouraged to look more and more like a Barbie Doll, it is truly disturbing to see our bodies being literally replaced with plastic dolls in the training of the professionals who will care for our bodies,” she wrote.

Despite the student uproar about the change to the status quo at Minnesota, it’s not as though the medical school is doing something all that radical.

M. Brownell Anderson, senior director of education affairs at the Association of American Medical Colleges, said her group had not considered students’ pre-clerkship experience with pelvic exams to be a contentious issue before hearing about the debate at Minnesota. “I don’t have any data one way or the other on what medical schools do,” she said. “It’s something we weren’t aware might be problematic.”

Medical schools have used standardized patients for only a few decades, and before that relied on mannequins that weren’t nearly as sophisticated as the models available today, Anderson said. “To learn how to do the exam -- where to place their fingers, what to feel for and that kind of thing -- it makes sense. It’s learning a technique in a way that is not going to cause anyone harm, not going to hurt a human being.”

Students, she added, still have plenty of opportunities to examine women during their clerkships and in residencies. “It’s not like this [one exam with a standardized patient] is their sole exposure to learning the genital urinary examination,” she said.

Laura Erickson-Schroth, a 2009 graduate of Dartmouth Medical School who is director of student programming at the American Medical Student Association, said that the group has no official position on how students ought to learn pelvic exams, though its constitution does support the use of trained patients.

But, in her experience, performing the procedure on a trained patient was helpful and comforting going into her third year. “It was great to have someone who had experience teaching students to walk us through the procedure,” she said. “It really helps to have patients who are comfortable enough with their bodies that they’re willing to go through something that for many people may be scary as a patient.”

The need for students to feel comfortable “speaks to the big problem with the pelvic exam,” said Adam Wolfberg, an obstetrician at Tufts Medical Center who wrote an article about how students learn the exam that was published in a 2007 issue of the New England Journal of Medicine. “Teaching anybody to examine a woman’s genitalia is fraught with embarrassment, stereotypes and concern about patriarchy and abuse.”

Alternatives to examining a live patient have been created to make the teaching and learning process easier.

About 100 medical and nursing schools use the METI Pelvic ExamSim, a sophisticated model with sensors that was developed by Carla Pugh, an assistant professor at Northwestern University's Feinberg School of Medicine. Pugh said the simulator is not intended to replace students' experiences with patients but to be a good way of introducing students to the procedure and to assess their skills. "I've never promoted mannequin-based trainers as a replacement for standardized patients," she said. "In my teaching, I have used a combined approach using mannequins, the simulator and patients."

(In clerkships, students sometimes practice the exam on anesthetized patients undergoing related surgeries. While that allows students to examine a real person, it’s not quite the same as working with alert patients who can say that a touch hurts or the speculum is cold, critics argue. There have been controversies over whether women need to consent to having the exam performed on them. The most recent debate erupted last month in Canada after a Globe and Mail columnist wrote about a young doctor’s survey of colleagues that began when she was a student at McMaster University.)

Whether a patient is awake or anesthetized for a pelvic exam performed by a medical student, Wolfberg said, “the most important thing is to communicate, to explain to the patient that a student is trying to learn and to ask for permission.” Patients, he said, when they are asked nicely, “are usually delighted to participate and give feedback.”

At Minnesota, the policy could change, said Allen, the course director. The school will survey students about their experiences performing “sensitive exams” on anatomical models, and patients to see if the change in second-year students’ instruction made a difference in how they performed in exam rooms with real patients. “It’s not at all our intent to get a student in an uncomfortable, unsafe environment.”

Wolfberg said the survey’s results would be helpful in determining how best to teach pelvic exams at all medical schools. “I don’t think there’s only one way to skin this cat.”