Pelvic exam by a medical student for the first time

by Paul B. Kubin

They say you never forget your first “real” patient.  Mine was a woman who didn’t need a pelvic exam, but who got one anyway.

Next door, minutes later, my second patient provided another personal first: a male genital and rectal exam, also, without need. Medical students like me begin training by practicing the basics on one another–listening to heart sounds, and looking into each other’s ears and eyes—but eventually, every clinician-in-training must lay hands on a complete stranger.  As medical students, this is a moment we look forward to as the official start to our medical career, and also dread for its awkward potential to demonstrate how much we have yet to learn.

Historically, it has been common practice for medical students to do full exams on each other, irrespective of their genders. Yes, you read that right.  Imagine being told to shuffle into an exam room with another student (male or female) to look at, listen to, and feel each other’s anatomy – and I mean all of it.  The rationale for this practice is the belief that the only way a clinician can understand what a patient goes through is to spend some time going through it too.  It’s an admirable goal, but let’s face it: your doctor or physician assistant, no matter how caring, is not your friend.

My school, a University of California medical school, did it this way until about 2004, and I give thanks every day that students are now broken in a little more gently.  Nowadays we only do the simple exams on each other while wearing shorts and shirts or bras.  Later, when it comes to the more “invasive” exams, we work with standardized patients. These are “real” strangers who are paid on a per-exam basis to provide the type of learning experience you can’t get from a plastic model.  Usually they are the first strangers we touch as medical students.

Despite the time spent preparing for my first standardized patient, the days leading up to the experience were full of dread.  I read my texts carefully.  I practiced on anatomical models.  My dreams were fraught with visions of passing out under the stirrups, or nervously saying something stupid, like “Well, everything looks great down here!”  I even asked my wife what a pelvic was like. “Honey,” she rolled her eyes, “you have no idea.”  It wasn’t helpful at all, but that was the point; I needed to figure it out for myself.

She was right, of course; I had no idea.  Thankfully my patient was a cheerful woman who had worked with students before.  She noticed how nervous I was, and made a joke or two to put me at ease.  She even gave me helpful feedback about my technique – feedback that I know better than to go into here.  Despite my fears, it turned out fine.  It was a great (if surreal) experience, and I realize now that everyone has to start somewhere, even if that somewhere is totally lost.

Paul B. Kubin is a physician assistant student who blogs at Inside PA Training.

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  • Stacey Burns

    Gynecological teaching assistants provide such a great service–both to clinical students and to every woman they will ever treat! The film-in-progress “At Your Cervix” takes a look at a darker practice: that of the history (and continuing practice) of practicing pelvic exams on anesthetized patients who haven’t given explicit consent. See At Your Cervix.

  • http://fertilityfile.com IVF-MD

    Thanks for writing on an topic that few non-students think about. I find it interesting that at your school, you still do preliminary exams on classmates, even if it is, as you say “in shorts, shirts and bras”.

    I am very familiar with the process of having students learn on dedicated paid mock patients as I am one of the faculty instructors for this ( also at a University of California medical school, such as yours ). This annual process for the 2nd year students is informally dubbed the Pelvic Workshop. It’s a very efficient model where classmates are grouped with 3-4 classmates. The models are very helpful and good at giving feedback. Each student performs the entire routine of breast exam, speculum exam and bimanual after I demonstrate it once. It’s especially efficient because each student not only learns by doing it himself/herself, but also from observing their colleagues. It’s an example of the value of med students learning by role-playing. Even when I was a medical student myself in the 1990′s, we had already been learning it this way.

  • Nerdy but not a clinician

    So a medical student performed intimate exams on two patients who didn’t clinically need it? WTH?

    I believe in the importance of helping learners, but if a student doc pulled this routine on me, a knuckle sandwich would have been delivered forthwith.

    It’s one thing if it’s clinically necessary but quite another if the only purpose is to help you burnish your skills.

    • Feb

      These were not actual patients who came to clinic with complaints; these were “professional” patients hired for exactly this purpose. My school did the same thing, and we considered these folks more than “models” and more like instructors. They not only know how the exam is supposed to go from the patient’s side of things, they know how to coach students on how to execute their skills so as to achieve the most clinically useful, thorough exam AND the least uncomfortable patient experience.

  • Premed

    Okay Nerdy, just think a minute. As a patient, would you seriously want a student that has never done a certain procedure performing one on you for the very first time (especially when medically necessary)? As a student learning such techniques, you have to start somewhere & it would be unethical practice to have student doing such exams on “real patients” for the first time.

  • Erin

    @Nerdy- The “patients” the student is talking about are people who are paid to teach students to perform pelvic exams. The “patients” are paid instructors, not real patients who just volunteer to get an unnecessary pelvic exam.

  • Stacey Burns

    Also, “Nerdy,” gynecological teaching assistants offer valuable feedback and, yes, instruction.

  • http://abnormalfacies.wordpress.com/ Jim

    I learned in the manner IVF-MD described, and thought it was a great experience (could have been much worse).

    Maybe it’s because she wasn’t my first “real” patient, but I think the only thing I’ll remember years from now is how one of the instructors squirted lube onto my shoe. In retrospect, that was the best icebreaker I could have asked for XD

  • http://www.atyourcervixmovie.com Amy Jo

    Gynecological Teaching Associates are well-trained teachers who probably know more about patient comfort than many providers because GTA programs across the country and in some other parts of the world have been working on making the pelvic exam most comfortable and respectful for patients for over 30 years. Indeed, my film, At Your Cervix (www.atyourcervixmovie.com) will explain the work we do and why it’s so very important. Check it out and please support us to finish the film if you can! Thanks for writing this!

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    “Thankfully my patient was a cheerful woman who had worked with students before. She noticed how nervous I was, and made a joke or two to put me at ease.”

    I’m not in any way questioning the value of these exercises, but shouldn’t it be the doctor putting the patient at east? Perhaps you should use standardized patients who are professional actors who can “act” uncomfortable, embarrassed, fearful of their modesty being violated, etc. Is this ever done? Cheerful, comfortable, happy, helpful, unembarrassed, standardized patients could and probably are giving new doctors the wrong idea about how the average, everyday patient really feels. I might suggest, if this isn’t happening already, that you try this, with both genders doing these intimate exams on talented actors who behave more like “real” not “standardized” patients.

    • http://abnormalfacies.wordpress.com/ Jim

      Doug,

      It most certainly is done. I’ve spoken with standardized patients (out of character) at my institution, and they are trained to throw us what they call “challenge questions” – e.g. “Am I going to die?” or “Yeah, I drink, doc, how much do you drink?”

      Many times, I’d argue, the standardized patients are over-the-top. Other times, they step out of their roles and act more as instructors – we still have to go through the motions and explain things to them as if they were a real patient, but it’s a low pressure environment because we can ask questions and correct ourselves during the encounter.

      I’ve had a fair amount of outside interaction with patients, and I can tell you that the average “real” patient is more timid/passive than the average standardized patient (until the invasive procedures begin, which we never preform on SPs anyway).

    • http://fertilityfile.com IVF-MD

      Rest assured that we do this. I believe practicing patient interaction with role-playing is a very natural valuable way to learn. There are times we have the model take it easy on the newbie to ease the nervous med student along and then as we advance, we make it an increasing challenge.

      And as Jim said, some of the model patients really ham it up.

  • Med Humanities

    Having some 20 yrs experience in gyn offices/Planned Parenthood, and having my share of pelvic exams, I always felt reactions to them were over-rated–unless, of course, the examiner is totally ham-fisted. The only one I remember negatively was done by a woman MD who, I swear, was going for a slam-dunk! Maybe I’m unusual, but I worked in an OB?GYN office w/ 2 docs. While one did my exam, the other would lean against the doorway & we’d have a 3-way conversation.

  • http://www.mypatraining.com Paul

    Yes, we do train with standardized patients who “act” as well. The program prefers the non-acting type for the teaching of sensitive exams so that students can learn the proper technique early on. It’s a good question – thanks!

  • Alina

    When did we start referring to PA students as “medical students?” We debate which titles that medical students (DO/MD) should use when introducing themselves to patients during clerkships, yet we don’t blink an eye at the title of this article. The titles we use and the letters behind our names took years to earn; they represent a specific sequence of training. Why not be proud of the accomplishments and work it took to become a PA student? It is disrespectful to other PA students.

  • http://www.mypatraining.com Paul

    Alina – I’m a medical student – I am studying medicine. If it makes you feel any better, I am a fully enrolled student at a University of California School of Medicine, so for me that’s kind of a no-brainer. I’m very proud of my accomplishments, and I don’t hide that I’m studying to become a physician assistant. I have great respect for both professions.

  • Alina

    Dear Paul – In your blog, under the entry from 26 Oct 2010, you wrote, “One of the things I love about the UC Davis program is the broad experience of the students. Nurses, EMTs, lab techs, radiology techs, therapists, corpsmen, you name it.” To clarify, you would have me as a PA student and all of the students studying to be nurses, EMTs, lab techs, radiology techs, therapists, & corpsmen identify ourselves to a patient as “medical students?”

    While we are all learning the art of medicine, I embrace our differences. It is the patient who suffers when the roles of their care providers are blurred. While all of the players on a football team have a common goal and wear the same uniform, ESPN doesn’t refer to every player as the starting QB.

    • Feb

      To extend your metaphor a little, ESPN does refer to “the Special Teams unit” or “the defensive line” when a group of players has a role to play that is, for the most part, very similar if not identical to that played by the next guy over – even if a cornerback is not “the same as” an outside linebacker.

      The job I do is one that’s also done by MDs (and NPs, actually) and I do it as the only practitioner in the building at the time. I’m practicing medicine; I’m not “physician assistant-ing.” I’m very happy and proud to be a PA, and I clearly identify myself as such with every patient, but I don’t feel like I’m cheating if I don’t add “it’s not like I’m a doctor or anything.”

      When I was in school, I refrained from saying I was “a med student” but that was out of not wanting to open this can of worms, not because it wasn’t true. I absolutely did say “I study medicine” and if asked, I followed that up with explaining I would be a PA (and if necessary, what that means).

  • http://www.mypatraining.com Paul

    It’s a great topic for discussion (“Should those in PA school refer to themselves as “medical students?”), and I’m open to all opinions. I’ve posted a simple poll on our site for readers to weigh in on the issue. The poll is for curiosity’s sake, not to prove or disprove anyone’s point of view. If you’re interested in voting, please check it out at Inside PA Training:
    http://www.mypatraining.com/pa-vs-md-are-those-in-pa-school-medical-students

    I’ve enabled comments so you can share your position if you care to. -PK

  • Sam

    As a fellow PA student, I would never think to label myself as a “medical student”. Medical students are in school to get their MD–yes we all are learning medicine, but it creates confusion where confusion isn’t needed.

    I, and you, am a PA student.

    • http://abnormalfacies.wordpress.com/ Jim

      I don’t think I’d call a PA student out for referring to him or herself as a medical student – they are indeed studying medicine. But nurses also study medicine, and I think people would be quicker to jump on one of them for doing the same. Where’s the line drawn?

      The point I do agree with is that there’s a lot of confusion out there (see the recent AMA survey released – shocking). I can’t believe sometimes that I have to qualify that I’m going to be a doctor after I tell someone I’m a medical student.

      I think it’s the worst, however, when female medical students have to deal with the “Oh, so you’re going to be a nurse?” comment. Yikes.