Pelvic exam simulators do medical students a disservice

Learning how to do a pelvic exam can be uncomfortable for medical students doing it for the first time.

There’s a trend in medical schools to use “simulators” and mannequins, rather than model patients, to teach students.

At the University of Minnesota medical school, tabletop anatomical models have largely replaced humans. Although the school denies costs are an issue, the savings are significant — currently it costs $150,000 to hire people to serve as standardized patients. Going with simulators can save several thousand dollars.

But some students are worrying that it can impact their education. And they’re right — no matter how good the simulator is, it cannot replicate an actual person. Especially for men, doing a pelvic exam is more than the procedure itself, but learning how to interact with the female patient from beginning to end:

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 pelvic exam as a second-year student, “the patient gave me all sorts of feedback and was really, really helpful.”

There’s no question that medical schools are facing more fiscal pressure than ever before. Already, more gross anatomy labs are substituting “virtual” bodies for cadavers.

Taking away the human element from medical education does our future doctors a disservice.

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  • http://www.nourishourselves.blogspot.com Marie

    While they should never replace actual real people completely, I think the simulators are perfectly fine for the initial teaching. I would think it is preferable to have students practice and commit any blunders on a mannequin before they go mucking about in someone’s privates. It also gives the student a measure of confidence in that when they do examine a volunteer patient, it is not an entirely new experience. They can focus more on the learning and less on their nervousness.

    When I was in nursing school we weren’t allowed to touch a real patient until we had practiced on models and each other. I think that is a good standard.

    • student

      Absolutely agree practice patients, whether each other or standardized, is the way to go. Can’t imagine having started on a simulator and then going to a patient room; seems downright unethical to me to do that to a patient in this special case. Though fiscal pressures in education are real, there are loads of areas to cut before these high yield sessions. As a secondary argument, I imagine skipping the standardized patient increases the likelihood of a negative first experience with a patient in the ob/gyn setting, hurting student interest in the field and in women’s care in general.

    • student

      Kevin, it’s all about money. Trust me. The medical school administration has allowed what was a wonderful medical school to fall into near-complete disarray…it’s very sad…and, contrary to what spokespeople might tell you, the fiscal shortcomings are not because of ‘the economy’ or the governor’s veto; they’ve been years in coming and the education was almost no different in flush years than in lean years (which is also to imply that it wasn’t particularly stellar overall, regardless of the condition of the balance sheet – primarily because there’s no individual accountability medical school-wide at any level)…

      I wish someone with some credibility – like you, Kevin – would help those in MN who want to maintain – and now, improve – Minnesota medical education. Those who care should clean out that school and return it to its proper place among the best public medical schools in the country. Short of that, the UMN will continue to fail ‘in the name of innovation’…take this from someone who watched the administration not be able to complete a significant project in 3 years that a small group of students who – out of hopeless frustration – took it on their own initiative and completed it in only 3 days. Again, very sad…

      - former, recent long-time student at the UMN Med School

  • robert

    I can’t honestly imagine learning a pelvic exam on a dummy – that would be a complete lack of an experience. I remember learning how to do the exam about a year ago and thinking ‘what was all the fuss about? this is fine’. Sure some of that is probably attributed to the fact that I want to enter OB/Gyn for a career, but there are many “worse” things that you do in medicine than that. Schools need to bear in mind that losing valuable first exposure is not worth a few thousand bucks. Cadavers and standardized patients are a key part of early medical education and need to stay in medical education.

  • Mary Bee

    Since the student is the beneficiary of these practice pelvic exams, why don’t they just volunteer themselves to be the “patient”. And the men could volunteer for testicular exam training.

    In addition to the school saving money and the student gaining practical experience, empathy would also be learned.

  • Erik

    Nothing in all of medical school was more painful, degrading or humiliating than my first “clinical exam” with a “trained expert” who was pretending to have pneumonia. I still have nightmares (even after passing boards and the recertification exam).

    Real patients are not in such short supply. Models and computer programs are nice, but real sick people are required to learn medical care. “Fake patients” do a huge diservice to medical education.

  • Erik

    Mary Bee, that’s exactly how “old-school” training went. Several of the MDs who precepted me in PA school related their tales of this kind of experience, which is arguably beyond empathy and into really weird territory … a little more intense than, say, a dental student having her teeth cleaned by a classmate, or a cook or waitron coming into the restaurant where they work and ordering a meal.

    Apparently there were two ways to approach the big day: a) pick someone you like, so you can go out for beers and gradually laugh off the intense oddness of having probed one another, or b) pick someone you don’t talk to much, and can avoid the rest of the school year.

    As a practical matter though, the (well-paid) volunteers who helped me learn pelvic and testicular/ prostate exams were dedicated individuals who often were cancer survivors, or doing it on behalf of a loved one who was affected by cancer. No fellow student nor real patient could have offered their specific and incredibly useful feedback.

    I credit these folks for making my actual patient exams much more effective and gentle – when I was still very new at pelvic exams, the best compliment I got from a patient was when she said, “wait, you mean that’s it?” It made me wonder how the person who did her previous exam had been trained.

  • http://fertilityfile.com IVF-MD

    Nothing wrong with having both. Simulator first and then real afterward. But I agree that a simulator does not even come close to fulfilling the requirements of medical training that comes from interacting with an actual human.

    As a former OB/Gyn resident, fellow and current professor, I have mentored many students in their first delivery and in their first pelvic exams and there is just as much anxiety in the latter as in the former. My suspicion is that during a delivery, there is screaming and blood and chaos everywhere, so the students get into this adrenaline rush mindset and are ready to deal with anything. Also, these are more experienced third-year students. During a second-year student’s first ever pelvic exam, the room is pin-drop quiet and they have to worry about every little detail such as if they are stuttering, their hands are shaking or if they’re breathing too loudly.

    Both of these, ones first pelvic exam and ones first delivered baby, are among the key rites of passage in the career of a medical student.

  • http://facebook.com/aurora.mditv Aurora

    I really like the idea that my doctors all practiced on real people before they were set free to practice on patients. I’ve been and the wrong end of several extremely uncomfortable examinations and the difference between those and the “that’s it?” ones is HUGE. More training on people who feel comfortable giving feedback is priceless.

  • minutemoon

    It’s interesting the the pelvic is used as an example here, with an emphasis on how male doctors need practice. How about testicular exams? How do female doctors feel about this? Don’t they need the same kind of clinical and communication practice? Or is it assumed that the other side of the coin isn’t as much of an issue. I think it is.

  • Kay

    You can say what you please, Most M. D.’s enjoy touching and taking advantage o f their influlence and position. A woman is very vunerable when they visit the Dr. and most take advantage of the situation.They will even ask if they can see you alone other than in the office. I know been there.

  • http://fertilityfile.com IVF-MD

    I would agree that the challenge of a male student doing his first pelvic exam is comparable to a female student doing her first testicular exam.

    I don’t think the difference in emphasis on pelvic exams over testicular exams is primarily a sexist one, but a logistical one. If you compare the number of pelvic exams done in this country daily to the number of testicular exams, it is a huge ratio.

    Part of is this is due to the fact that unlike self-breast-exams and self-testicular-exams, it’s nearly impossible to do a self-pelvic-exam. Having said that, I have heard of women who have done their own pap smears and even one who successfully did her own intrauterine insemination, so who’s to say?

  • minutemoon

    “I don’t think the difference in emphasis on pelvic exams over testicular exams is primarily a sexist one, but a logistical one.”

    Perhaps logistical to a certain degree. But I also think it’s cultural — involving attitudes regard nudity and how men perceive naked women and how women perceive naked men. I think there’s a significant amount of invisible, unspoken cultural baggage associated with procedures like these.