Being able to perform an adequate and thorough gynecological examination is an important clinical skill for every physician and one that medical students must acquire. During the obstetrics–gynecology clerkship, medical students have opportunities to practice gynecological examinations with pelvic training mannequins and/or gynecological teaching associates, both of which have important pedagogic value.1,2 Studies have demonstrated the value of involving real patients in medical education as well, describing patients as active partners in clinical teaching.3–5
Instances in which patients do not permit medical student involvement in gynecological examinations do occur, however, leaving students with fewer opportunities to develop the necessary clinical skills.6–10 Previous studies have demonstrated that 75% to 87% of gynecological patients accept medical student involvement (partly or entirely performing the exam) in their examinations.6–9 The reasons patients gave for allowing student involvement include the desire to contribute to students’ education, the opportunity to learn more about their treatment when the physician is teaching the student, and/or previous positive experiences with medical student involvement.7,8,10,11 In addition, studies have found that patients who are older, who have higher parity and higher education, or who are Caucasian are more likely to accept student involvement.8,10–13 Patients’ main reasons for refusing to allow medical student involvement include the wish for privacy and uncertainty about the degree of student participation in the gynecological examination.6–8,10,11
Students’ gender can also affect their participation in gynecological examinations. Several studies have demonstrated that male students face a disadvantage compared with female students in terms of involvement in gynecological examinations and the embarrassment experienced during the examination by patients.8,10,11,14–16 Furthermore, teaching physicians are less likely to introduce male students than female students to their patients.14 Two studies have shown that a majority of male medical students (78% and 64%, respectively) felt their gender adversely affected their experiences during their obstetrics–gynecology clerkship.15,17
Most previous research exploring the reasons why medical students are not allowed to perform exams has focused on the patient perspective. To our knowledge, research exploring medical students’ experiences and perspectives on this issue is limited. Furthermore, the role of the supervisory physicians in the students’ participation is underexposed.
Therefore, we performed this study with the following goals: (1) to determine how often gynecological patients at hospitals affiliated with our medical school in the Netherlands refuse to allow medical student involvement in their examinations and to ascertain whether there is a difference in their frequency of refusing consent for male students and female students; (2) to explore the role of the supervisory physician in instances in which students are not allowed involvement and identify key physician- and patient-related barriers to medical student involvement in gynecological examinations according to students’ perceptions; and (3) to determine the impact of not being allowed to participate.
In this two-part study, we first collected quantitative data using a questionnaire and then conducted focus groups to collect qualitative data. All 139 Radboud University Medical Centre (RUMC) medical students entering their eight-week obstetrics–gynecology clerkship between May and October 2011 were invited to participate in the study.
RUMC is located in Nijmegen, The Netherlands. Its medical school curriculum spans six years. After students finish the first three years of medical school, in which theoretical knowledge is taught, they complete a standard three-year rotation program of clerkships. Each clerkship is preceded by a short course. Before students begin the obstetrics–gynecology clerkship (which occurs in year 5 of the curriculum), they take a one-week course in which they practice vaginal (bimanual pelvic) and speculum gynecological examinations on pelvic training mannequins and gynecological teaching associates.1,2 Students complete this clerkship in various nonprivate hospitals: the university hospital (RUMC), which provides both secondary and tertiary care, or 1 of 10 local hospitals that provide secondary care and are affiliated with the RUMC. Students are only allowed to perform gynecologic examinations on a patient after the patient has provided explicit oral permission. At the end of the clerkship, students are expected to be able to perform solid and systematic gynecological examinations. Medical student involvement in this study means performing the entire gynecological exam (both speculum and vaginal) by the student, supervised at all times by a resident or physician (supervisory physician) who is in a teaching role during the clerkship.
In the week before the students started their clerkships, we informed them about the study and invited them to participate. We asked them to provide demographic data and record on the study questionnaire each day the number of gynecological exams performed and disallowed (i.e., patient or physician did not give permission) in the gynecology outpatient department (patients with obstetrical problems were not a focus of the study). When students were not allowed to perform an examination, we asked them to indicate whether it was due to the patient or the supervising physician disallowing it. Questionnaires were completed on paper and returned on completion of the clerkship. Students provided their name and e-mail address on the questionnaire. All students (responders and nonresponders) received one reminder, and students were not offered an incentive for participation.
After students who completed their clerkships in May, June, and July 2011 returned their questionnaires, we randomly selected and invited 18 who reported at least five disallowed gynecological examinations to participate in focus groups. The students were invited by e-mail and offered a lunch. Our goal was to identify, from the student perspective, the most important patient- and physician-related barriers to medical student involvement in performing part or all of the gynecological examinations.
Each of the three focus groups consisted of six students. The first focus group consisted of six male students; the second, three male and three female students; and the third, six female students. We chose this approach to expose any explicit differences between male and female students’ experiences and perceptions. Saturation was reached after three focus groups, when no new themes emerged. All focus groups took place at the RUMC. A female moderator (K.M.) directed the focus groups, each of which lasted about one hour. In the focus groups, we investigated the experiences and opinions of medical students using a topic guide (see List 1). We developed this topic guide in line with the current literature and expert opinions, and we tested it in a pilot group (before the three focus groups) observed by an experienced focus group leader. Two observers (L.E. and M.K.) were present during all focus groups. All discussions were fully recorded on audiotape and transcribed by one observer (M.K.).
Data were analyzed using SPSS software (version 16.0 for Windows, Chicago, Illinois). Medians were compared using the Mann–Whitney test. We considered P < .05 statistically significant. We entered all focus group transcripts in ATLAS.ti (Visual Qualitative Data Analysis–Model Building Version WIN 4.2 GmbH, Berlin) to structure the qualitative data. We used the content analysis method to anonymously code and analyze the transcripts.18 Two members of the research team (L.E. and M.K.) coded the transcript from the first focus group independently. They discussed any discrepancies and, if necessary, asked a third member of the research team for advice to reach agreement. The second and third focus group transcripts were coded by one researcher (M.K.).
The institutional review board of the RUMC Nijmegen determined that their review of the study protocol was not required.
Of the 139 medical students (44 male [32%] and 95 female [68%]) invited to participate, 76 students (55%; 23 male [30%] and 53 female [70%]) completed the questionnaire. They reported a total of 2,196 disallowed gynecological examinations and 2,973 performed examinations, for a permission rate of 58%. Table 1 provides the demographic data of the study population.
The median numbers (range) of performed and disallowed gynecological examinations were 30 (4–189) and 26 (0–120), respectively. The number of performed and disallowed examinations did not differ significantly between male and female students. The median number (range) of performed vaginal examinations was lower in comparison with speculum examinations, 8 (0–62) versus 21 (4–127), respectively. Some students never performed a vaginal examination during their clerkship (Table 2). Of the total 2,196 disallowed examinations, students reported that 1,956 (89%) were related to the supervising physician. The median (range) of physician-related disallowances was 22 (0–120) overall; it was 22 (0–80) for male students and 23 (0–120) for female students. The remaining 240 disallowances (11%) were related to the patient, with a median (range) of 1 (0–34). The median numbers of patient-related disallowances were 4 (0–34) for male students and 1 (0–15) for female students; this difference was statistically significant (Mann–Whitney test, P < .001; see Figure 1).
The median age (range) for focus group participants was 23 (22–24). Three participants completed their clerkships at RUMC, and 15 completed their clerkships at a general hospital. Table 3 shows the number of performed and disallowed examinations among participants. The themes that emerged from the focus groups were (1) the barriers and facilitators encountered in performing gynecological examinations, categorized by physician- and patient-related factors; and (2) the impact of disallowances (i.e., being refused permission by the patient or physician).
Barriers and facilitators: Physicians’ role.
The students considered the supervising physician to be the most significant barrier to their performing gynecological examinations. They described two types of physician-related disallowance: passive nonpermission and active denial of permission. In instances of passive nonpermission, the physician performed the examination without involving the student or asking the patient for consent to have the student perform it. Such disallowances were frequently cited as discouraging experiences.
Physicians have to realize that students have to practice these examinations. Many physicians do not realize this; they are just doing their job. They quickly perform a speculum examination and that’s it. And then afterwards they say, “Oh, you should have done that.” (Male student, focus group [FG] 1)
In an active denial of permission, the physician explicitly barred the student from performing the examination. The reasons students reported being given for active denials of permission were lack of time, a complicated examination, or the fact that the patient was an acquaintance of the physician. In most cases, students understood these reasons.
The physician often said, “I’ll just do this one, as this patient seems very nervous” or the physician was “short of time.” (Male student, FG 2)
All of the students emphasized the importance of the way the supervisory physician introduces the student to the patient. They believed that asking the patient for permission in an extended and tendentious way increased the number of patient refusals. Some students said that female physicians were more likely than male physicians to give a too-comprehensive introduction.
Some physicians repeatedly asked the patient, “Is it okay if a medical student is present during the examination?” followed by: “Is it really, really okay if the medical student performs the examination?”… I really felt that frequently asking the patient for permission created a threshold for the patient to say “yes.” I understand that it needs to be asked, but there are other ways to do so. (Male student, FG 1)
The students stressed the value of a decisive and concise introduction of the student to the patient. One student highlighted the ethical concerns about the use of such an introduction.
An introduction, before asking for consent, such as “Today I’ve brought along a future colleague, and we are doing the examination together,” made a refusal much less common. (Male student, FG 1)
Furthermore, the students believed that patients were less inclined to refuse permission if the students were more involved in the consultation. They suggested that their involvement might be increased by having them introduce themselves to the patient, invite the patient into the consultation room, or take a history. One student explained that both the physician and the student have to make an effort.
On the one hand, physicians have to be aware of the fact that students need a chance to learn to do these examinations. On the other hand, many physicians believe that it’s the student’s responsibility. I think it would be useful to give the medical students instructions before the clerkship emphasizing the importance of being assertive. (Male student, FG 2)
Most students reported encountering fewer disallowances among older and more experienced physicians. The students reported that younger physicians were often too much involved in their own learning process and regularly faced time barriers. Physicians with specific educational tasks (e.g., physicians who often teach at the university or personally mentor medical students) were described as more inclined to allow medical students to perform examinations because they were aware of the students’ learning goals.
All of the participants emphasized that physicians should recognize their role in disallowing gynecological examinations and acknowledge their role as supervisory physicians. Some students emphasized the importance of educating physicians about the competencies medical students are expected to demonstrate.
I think that, if gynecologists were more aware of medical students’ skills and learning goals for this clerkship, it would be much more natural for them to let us perform gynecological examinations. (Female student, FG 3)
Some female students reported encountering hierarchical barriers when asking a supervising physician for permission to participate, even before the patient was asked for permission. In general, female students considered themselves less assertive than male students. A positive bond with the physician was considered to be a facilitating factor in asking for permission.
I usually didn’t really ask the physician for permission to be involved in performing an examination; I did all the preparations for the examination … and hoped I could continue and actually perform the examination. (Female student, FG 3)
Whether it was difficult to ask the physician depended on the physician you were working with … whether you felt a connection with him or her. (Female student, FG 3)
Some male students suggested a more subtle way of creating opportunities to perform gynecological examinations without explicitly asking the physician’s permission.
If I had been refused permission a couple of times in a row, I would usually give a hint, like: “Should I put on gloves?” (Male student, FG 1)
Barriers and facilitators: Patients’ role.
The students believed that patients refuse medical student involvement in gynecological examinations because of a wish for privacy, a history of sexual assault, fear of pain, religious rules, or being younger. Furthermore, the students reported that patients who were visiting the outpatient department for the first time, had vulvar pain syndromes, and were acquaintances of the physician or of the student are less likely to permit exams by medical students. Some students also said that medical students’ lack of experience and the patients’ lack of awareness of the medical students’ roles were reasons for patient refusals. The students believed that older patients, patients with positive experiences with medical student involvement, and patients with higher parity were more likely to give permission.
All of the participants observed that male students were more often refused permission by patients than were female students. The students emphasized that patients’ religious beliefs, young age, or embarrassment more frequently acted as barriers for male students than for female students. Some male students reported that they were refused less often when they were working with male physicians. They believed that patients who prefer female physicians might be less likely to allow male medical students to be involved in their examinations.
Most male participants did not think that being refused had much impact on a personal level (e.g., increasing their insecurity), but they agreed that it was unfortunate for their learning experience and it made their day less interesting.
Female students reported experiencing more personal impact than did male students. Female students felt insulted and offended when they were refused. Female students were more likely than male students to talk about the personal impact of refusals in the all-female focus group than in the mixed-gender focus group.
Eventually I had to leave, and those are the times I really feel like a doormat…. It is a typical case of feeling like a medical student who is good for nothing. (Female student, FG 3)
Female students commented that physicians’ passive nonpermission was disappointing. Some said that it made them feel insecure about their gynecological competences.
Although most male students assumed that many patient refusals were due to their gender, only one explicitly reported this as a negative experience. Male students felt more discouraged about being refused as a result of the physician’s extensive introduction.
In this study, we explored students’ experiences and perceptions of patient- and physician-related barriers to their participation in gynecological examinations during their obstetrics–gynecology clerkships. One important finding of our study is that students reported that patients more often refused to allow male medical students than female medical students to perform examinations; this is consistent with the literature.8,10,11,14–16 Our study also reveals several other barriers to patients accepting medical student participation, which are consistent with the literature: the wish for privacy,6,8,10 the patient’s age,8,10,13 and the patient’s religion.19
To the best of our knowledge, our study is the first to show that supervisory physicians play a major role in disallowing student participation in gynecological examinations. Physician-related disallowances involved a complex, triadic interplay between student, teacher, and patient, and took the forms of active denial of participation and passive nonpermission. Our focus group participants emphasized two significant dynamics at play in “passive nonpermission.” First, students, physicians, and patients have their own priorities, which can conflict. Students want to improve their competency as much as possible; given that more practice improves skills, the students want to perform gynecological examinations as often as they can. Patients may give reasons such as privacy, autonomy, or religious barriers as reasons for refusing student involvement. Both medical students and supervisory physicians must try to balance students’ learning needs with their ethical obligations, such as protecting patient autonomy, especially for patients who are vulnerable.20 Older and more experienced supervisory physicians disallowed student involvement less often. Students suggested that this may be because younger physicians may be involved with developing their own competencies and therefore disallow student involvement unintentionally. Other explanations may be that younger physicians experience more difficulties with time management or may be more sensitive to the patient’s needs than older physicians.
The second dynamic is the role of gender in the triadic interplay between student, patient, and supervisory physician. Students stated that female physicians were more likely “to introduce the student too comprehensively.” This suggests that female supervisory physicians may be more likely than their male counterparts to prioritize the patient’s autonomy and wishes above the student’s learning goals. Some male students expressed the opinion that patients who prefer a female physician may be less likely to allow a male medical student to be involved. They suggested the use of somewhat biased introductions like “Today I have brought along a future colleague.” There are clear ethical issues about using terms like “future colleague,” which blurs the student’s identity; however, this was highlighted by only one of the students. Male students appeared to have trouble understanding or accepting this dilemma, stating that being refused involvement by a patient because of an extensive and cautious introduction discouraged them. Female students felt that instances of physician “passive nonpermission” were disappointing. They indicated that they felt a hierarchical barrier and as a consequence were less assertive than male students in asking permission to perform the examinations; some female students only asked questions if they felt connected to the supervisory physician. This shows that the relational aspect is important to female students, who, unlike male students, are more intimidated by the hierarchy and therefore feel less free asking for training. The role of gender seems important and needs further exploration.
The quantitative data show that medical students performed fewer vaginal examinations than speculum examinations. In fact, some students reported that they never performed a vaginal examination during their eight-week clerkship. This partly might be explained by the frequent use of transvaginal ultrasound, which we have observed in our experiences in the clinic. Nevertheless, medical students are not offered enough opportunities to practice the vaginal examination, which is a necessary skill for every future physician because it may reveal specific information and because ultrasound is not available everywhere. However, changes have to be made to ensure that students receive more opportunities to practice and to make the vaginal examination a feasible learning objective for obstetrics–gynecology clerkships.
The strength of our study lies in its dual nature. The quantitative and qualitative data increased the reliability and depth of the results, identifying key areas for improvement.
We found that the permission rate for student involvement (58%) was significantly lower than the 75% to 87% demonstrated by other studies.6–9 Although there is a difference between these previous studies and ours, comparison is limited, mainly because of differences in definitions and methods. In some other studies, all outpatient department patients were included, whereas in our study only patients attending the clinic for gynecological reasons were included. Two studies7,8 showed that patient permission rate was significantly higher in women who attended the clinic for obstetric reasons. Another important difference is the definition of permission. In some other studies, permission is defined as “medical student involvement,” which does not necessarily mean performing a gynecological examination, whereas in our study it does.
A limitation of our research is the low response rate. It is possible that the medical students who completed the questionnaire were disallowed more often, which may have biased the results. Future studies should investigate the physicians’ perspective. This would give us more insight into physicians’ reasons for not allowing medical students to perform gynecological examinations.
Finally, our findings emphasize the importance of raising physicians’ awareness of their role in not allowing the students to perform examinations; the interaction between the patient, student, and physician; and the role of gender. Educators could help physicians without educator roles to cope with these issues by actively communicating with and involving students.21 Ultimately, improving communication and increasing physicians’ awareness of their teaching role might create a better and more effective learning environment that would maximize the medical students’ clinical experiences during their clerkship.
In conclusion, our study demonstrates that the role of the physician in allowing or not allowing student involvement is substantial and results in fewer opportunities for medical students to perform gynecological examinations. Gender and the complex interplay between student, patient, and supervisory physician play an important role in the factors that contribute to physician-related disallowances.
Acknowledgments: The authors wish to thank K.A. Meeuwis and M. Oudenhuysen for their excellent assistance in moderating and help with the focus groups.
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