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Gloved and ready, I began my examination of Linda’s genitalia. Following my instructions carefully, I inserted my fingers into her vagina and palpated her glands at 10 o’clock and 2 o’clock. We were told to think of the vulva as a clock face. I found myself being self-conscious, feeling as though fumbling in a pelvic exam would imply some sort of sexual inadequacy. I can’t tell you how uncomfortable it is to be touching a woman in such sensitive, private areas with the fear that you will hurt her or accidentally cross some line and touch her inappropriately.
I’d always assumed that for my first female breast and pelvic exam I would observe doctors performing on patients and then have my turn while they pointed out my mistakes. But at the Albert Einstein College of Medicine, where I am a second-year medical student, and at most med schools today, it no longer works that way. Einstein hires a group of women professionally trained to teach students how to perform breast and pelvic exams. And they teach us how to do it on themselves by themselves.
We were assigned dates for our pelvic exams a month prior. I was assigned to the last day and had the privilege of hearing all about it. One friend told me that it wasn’t so bad, but he was uncomfortable, sweating profusely throughout. Another described the experience as so rewarding that he jokingly asked if I would give up my spot so he could have a second go. Sweaty for some, addictive for others? Sex was the last thing I wanted to think about going into it. What could be more inappropriate than thinking about sex while you are examining a patient with that confidentiality and trust? And yet, there are definitely male medical students for whom this female pelvic exam is their first contact with female genitalia since birth. I worried, is it possible to completely eliminate those thoughts?
One night last fall, three female fellow med students and I went into a small examination room to meet Linda (not her real name), a 42-year-old real estate agent, who was patiently sitting on the examination bed in her gown. We started with role-playing doctor-patient situations, with Linda telling us what questions to ask her and what instructions to give her as doctors. I tried to internalize every detail. Sure, I wanted to learn how to do it right, but mostly, I didn’t want to embarrass myself.
The breast exam was first. Linda told us to respect the patient’s modesty, exposing as little skin as possible. Then we took turns examining one of her breasts, moving our fingers in circles, palpating for abnormalities, and then examining her nipple for potential discharge. When my turn came, I was nervous, but I think I hid it pretty well. I started moving my fingers beginning at the tail of her breast (up by the armpit), working my way down and around. “You’ve got to push harder than that or you’re not going to feel anything!” Linda commanded. I was erring on the light side because I didn’t want to be violating her, but I dutifully followed her instruction, simultaneously discussing the ins and outs of breast self-examination. Afterward, Linda told me that I’d forgotten to suggest exams in the shower, so I added, “And since it’s easier to do with the water flowing, you can do it in the shower.” She then pointed out that to avoid unwanted double entendres in the future, I should avoid the phrase “Do it in the shower.”
As the other students did their pelvic exams, I felt at ease and thought smugly, “I don’t know why I worried that I’d think about sex.” This thought was quickly followed by a realization: “Oh shit! I’m thinking about sex now!”
Now it was my turn. Heeding Linda’s advice, I minded my vocabulary: Don’t say “spread your legs,” say “move your knees to each side.” Don’t say you’re “looking for cancer,” say you’re “making sure everything is normal.” She told me to put the mirror in the patient’s hand to encourage her to be involved. Linda bragged that her cervix was “beautiful.” She told me that it was hard to palpate her left ovary, but she could tell what I was feeling. That way if she asked me, “Do you feel my ovary?” and I said, “Yes,” she could correct me with “No, you don’t. Try again.”
Before I inserted the speculum into her vagina, Linda lubricated the plastic instrument. You need to, if inexperienced med students are performing four pelvic exams on you in one night. With one hand on her abdomen and two fingers in her vagina, I tried to sense her ovaries, but could hardly feel them. Linda comforted me by telling me they were difficult to feel.
Later I wondered where the school found these women. What motivates them? And is this the best way to introduce students to these exams?
According to Dr. Nadine Katz, who organizes the pelvic exams at Einstein, most med schools currently use a similar model in which the initial encounter is with these paid gynecologic teaching associates (GTAs). Thirty years ago, a student’s first experience was always with an actual patient. Today, in the second pre-clinical year, the student is introduced to the exam in this educational rather than clinical setting. For follow-up, during his or her OB-GYN clerkship (in the third year at Einstein), the student will examine a real patient while being observed by a faculty member. By breaking it down this way, the idea is that first, patients will be protected, and second, students can relax since their first pelvic is in a non-threatening, non-graded environment. Katz said the program has met with overwhelmingly positive feedback from students.
The Teaching Associates Program of New York has provided similar services for 20 years, supporting almost every med school in New York City. Program coordinator Sau-fong Au told me that GTAs are recruited through hospitals, health care and women’s advocacy groups, and word of mouth. Associates must complete 60 hours of training before they are sent out to teach. In programs Au supervises, GTAs may demonstrate breast and pelvic exams on each other before students have their turn. Students generally have three main concerns: thoughts about sex, hurting the patient, and doing it right. As far as the women’s motivation, they are “well compensated,” but mainly, Au cites their devotion to improving health care. Some of them may have had poor experiences with doctors, and what could be more empowering than teaching future doctors how to do it right? And who better to teach than women who know and are comfortable with their bodies? Au emphasized that respect is due these women, and that some may falsely see them as “easy women” for being so open, an image not helped by the fact that when these programs began 20 to 30 years ago, many teaching associates were prostitutes.
I may not see myself as a future OB-GYN, but I got through my first breast and pelvic, and it turns out, I think I can handle this. But there’s no time to relax. Next week, I’ve got my first male genitourinary and rectal.