“Is this your first pelvic exam?”
No, replied Amanda Struiksma. It was in fact her eighth – in less than an hour.
Struiksma is a “model patient,” helping first-year internal medicine residents from the University of Washington learn how to approach a procedure at once intimate and clinical.
She kept a straight face answering the question the first seven times. But now she slipped, and a half-smile appeared. The three residents in the exam room, including the young man who posed the question, chuckled, too.
Some of the room’s nervous tension dissipated.
Just a few decades ago, it was common to practice pelvic exams on women anesthetized for surgery. That taught medical students and residents the technique, but knocked-out women don’t have much feedback to give. Here at a Planned Parenthood training, the residents were taught not only how to handle a speculum but also how to make the inherently awkward exam a little less awkward.
It’s small things – like asking whether it’s the patient’s first time or saying “foot rests” instead of “stirrups” – that add up to make a difference. Model patients give feedback specifically on how the residents made them feel, which represents a cultural shift from the days of practicing on anesthetized women without consent.
Good bedside manner
Training for bedside skills has become an increasingly important part of medical education in recent years. Medical schools used to dump technical knowledge on their students and send them out into the hospital to deal with patients right away. Somewhere along the way, young doctors were supposed to figure out how to talk to patients.
“Historically, we’ve thought, ‘You’re a nice person; you can figure it out,’ ” said Dr. Karen McDonough, who teaches Introduction to Clinical Medicine at the University of Washington School of Medicine. Now the thinking has changed: “Communication skills are something that can be learned just like surgeries.”
For example, it can be counterproductive to say “tell me if it hurts” to a woman about to get a pelvic exam, which is uncomfortable but not usually painful. Those words, however well-intentioned, make patients tense up, expecting the worst.
Because of a patient’s deeply held personal or cultural beliefs, women’s sexual health can be difficult to talk about. Add in the procedure’s invasiveness, and the routine pelvic exam can be especially fraught. In these sensitive situations, a doctor’s composure and choice of words can make a world of difference.
On a Monday evening in Planned Parenthood’s Seattle headquarters, first-year internal medicine residents ate their sandwiches to what sounded like the click-clack of silverware. The sound was actually from speculums being laid out for a lecture before the practice session. It’s just background noise now, but those sounds matter in the exam room.
“It’s my pet peeve,” said Dr. Alson Burke, who teaches gynecology to med students and other residents at the university. “Even when it’s just an instrument making noise, the patient hears click click click and crunch crunch crunch, and she thinks, ‘Oh my god, what is the doctor doing down there.’ I teach the residents to manipulate instruments without the noises.”
Specific lessons like these demonstrate recurring themes in proper bedside manner.
It’s recognizing a patient’s apprehension of the unfamiliar: The speculum, sometimes described by women as resembling a torture device, is used to open the vagina for the exam. Students are taught to let women who seem especially nervous hold the speculum first and even place it themselves.
And it’s letting patients be in control: Instead of pushing a patient’s legs open, a doctor can place his or her hands on either side and say, “Let your legs fall naturally until your knees touch my hands.” Instructors tell students to be especially sensitive that women may have experienced sexual assault, which may influence how they react to the procedure.
Dozens of these small interactions during an exam are carefully mapped out.
The training session for first-year internal residents, which University of Washington contracts to Planned Parenthood of the Great Northwest, takes place after-hours at the clinic. After a lecture, residents in groups of three rotate through exam rooms, each staffed with a registered nurse and a model patient, both paid for their time.
Both the preceptors and the model patients are drawn from Planned Parenthood staff, who view this training as part of the organization’s role in promoting access to women’s health.
“We’re the people most comfortable about it,” says Struiksma, a patient-care coordinator who’s worked at Planned Parenthood for four years and been a model patient for two. “If not us, then who else?”
The model patient
Experienced model patients are also comfortable giving feedback where nervous or confused real patients might be silent.
Relying on the kindness and consent of patients for practice runs into other problems, too.
“Lots of patients aren’t comfortable with a medical student, especially male medical students,” said Dan Arnett, a first-year resident who had done an OB-GYN rotation while in school. Male students are usually more nervous practicing the exams, too.
Model patients also have become a larger part of medical education in general. In these simulated situations, students can make mistakes without affecting an actual patient’s health. Model patients act in all sorts of different patient roles, but gynecology presents a situation where it gets especially hands on – just as real doctors have to do.
“They’re absolutely amazing,” says Burke of the model patients in the OB-GYN class she teaches at the university. “Ninety-nine percent of the learning are these women who give their time and essentially their bodies.”