“Ma’am… Can you lift your breast please?”
I got to the cardiac auscultation station of my clinical examination—a station I was relatively comfortable with—and read the instructions while waiting for the buzzer to sound. When it finally rang, I opened the door and my heart sank: the patient-actor was a woman.
For the previous few weeks, my classmates and I had spent our evenings perfecting our physical examination techniques for the examination. During one of those late night practice sessions, we realised we were not confident on how to perform the cardiac examination on a female patient. Where do you put your hand when you are feeling for thrills? What do you do with the patient’s bra? If the patient’s breast is in the way, do you move it gently aside, or do you ask the patient to do so? We had a lot of questions that most clinical textbooks do not cover. Finally, we gave up trying to find the answers, dismissing the possibility of even having a female patient because we thought it would be easier for examiners to get a male patient to volunteer. We reasoned that when we were learning the cardiovascular examination, it was taught by demonstration on a male classmate. When we practised our auscultation skills, it was on a male mannequin. Finally, when we were taken for bedside tutorials to perfect our examination technique, we were usually taken to a male patient on the ward. On this basis, we assumed that teaching staff would not change their approach and have a female patient-actor at our cardiovascular station. But on exam day that turned out not to be the case, and many of my classmates, both male and female, conducted their first cardiovascular examination on a female patient.
This scenario has raised several problems. I believe that there is a lack of teaching on how to perform examinations on female patients and a lack of resources—for example, textbooks and videos—to complement teaching on this topic. Both these problems, once acknowledged, can be easily remedied and introduced to the curriculum.
The awkward social barrier between female patients and medical students is taken into account when developing the teaching curriculum of sensitive examinations, such as breast examination. The result is that students are given opportunity to practice on female mannequins and staff members facilitate consent from patients. However, routine examinations, such as that of the cardiovascular system, are not often recognised as a limiting factor so these interventions have not widely been put into place.
The lack of opportunity to practise techniques on female patients is not so easy to overcome. It is possible that many medical students graduate without gaining sufficient experience in conducting routine examinations on female patients. It is understandable that some female patients might feel uncomfortable being examined by a student (male or female) in an examination that requires the chest to be wholly or partly exposed, but what happens a few years down the line when that student becomes a doctor who has limited experience of examining female patients? This raises the question as to whether performing a physical examination is so different from other key clinical skills, such as a medical student delivering their first baby, or taking blood for the first time? These situations might be difficult for the patient, but they ensure that the future generation of doctors has the necessary clinical experience to be safe and effective.
One part of the problem is that students, especially male students, are aware and worried that there is a chance they will be declined consent to conduct a cardiovascular examination on a female patient. This is supported by a large observational study that found that although overall patients were comfortable with both student genders, significantly higher comfort levels were reported with female students compared with male students. It is important to note that opportunities to practise examination technique on women, especially for male students, might vary depending on geographical, cultural, and religious factors.
Alongside improving teaching resources, a potential solution that could increase opportunity to examine female patients might be for students to be introduced as an integral part of the clinical team, rather than an adjunct. If medical students were the first point of contact for patients requiring physical examinations, for example, female patients might be more willing to consent, providing the student with a crucial learning opportunity.Pishoy Gouda, fourth year medical student
1National University of Ireland, Galway
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
- Sakala EP. A comparative study of fears and anxieties of student physicians anticipating the female pelvic and cardiac exams. J Psychosomatic Obs Gynecol 1987;7:19-26.
- Passaperuma K, Higgins J, Power S, Taylor T. Do patients’ comfort levels and attitudes regarding medical student involvement vary across specialties? Med Teach 2008;30:48-54.
Cite this as: Student BMJ 2013;21:f7377