'Poorly relaxed women': A situational analysis of pelvic examination learning materials for medical students.
Journal
Medical education
ISSN: 1365-2923
Titre abrégé: Med Educ
Pays: England
ID NLM: 7605655
Informations de publication
Date de publication:
07 2022
07 2022
Historique:
revised:
04
01
2022
received:
24
06
2021
accepted:
17
01
2022
pubmed:
28
1
2022
medline:
10
6
2022
entrez:
27
1
2022
Statut:
ppublish
Résumé
Certain clinical pelvic examination (PE) teaching methods have been critiqued for prioritising student learning over patient autonomy and for not accurately representing diverse patient communities. As such, patient-centred and culturally competent approaches to the PE may need further emphasis in the medical curriculum-in particular, in content delivered to students before patient interaction. Classroom materials serve as students' first exposure to the sensitive procedure. This research explores how patients are represented in these materials. A situational analysis was conducted on 10 purposively sampled PE learning materials for the 2019/20 academic year from five undergraduate medical schools in Canada. Situational analysis focuses on analysing discourse but is epistemically aligned with post-structuralism (most notably Foucault's theories involving discursive power) and allows for specific consideration of 'silences' in the data. Collected data were analysed using cartographic approaches according to this methodology, with particular attention paid to the tenets and frameworks of patient-centred and culturally competent care. Overall, content in these materials misrepresented and under-represented patients. Materials contained both outdated and unnecessarily sexualised language, in addition to a lack of patient diversity. Clinical authority was often centred over patient agency, and several updated PE techniques known to improve patient experience were absent. Patient-centred and culturally competent approaches were therefore inadequately highlighted in most of the materials. Depictions contained in these materials may be perpetuating stereotypes and biases in medicine and may be working to maintain teaching practices that cause harm to patients (standardised and regular) who students interact with in both clinical and educational settings. Efforts may be needed to improve classroom materials on the PE so that they more adequately centre patients and provide opportunities to discuss culturally competent approaches to the procedure that (i) may not be covered in other parts of the PE curriculum and (ii) can reduce known health disparities.
Sections du résumé
BACKGROUND
Certain clinical pelvic examination (PE) teaching methods have been critiqued for prioritising student learning over patient autonomy and for not accurately representing diverse patient communities. As such, patient-centred and culturally competent approaches to the PE may need further emphasis in the medical curriculum-in particular, in content delivered to students before patient interaction. Classroom materials serve as students' first exposure to the sensitive procedure. This research explores how patients are represented in these materials.
METHODS
A situational analysis was conducted on 10 purposively sampled PE learning materials for the 2019/20 academic year from five undergraduate medical schools in Canada. Situational analysis focuses on analysing discourse but is epistemically aligned with post-structuralism (most notably Foucault's theories involving discursive power) and allows for specific consideration of 'silences' in the data. Collected data were analysed using cartographic approaches according to this methodology, with particular attention paid to the tenets and frameworks of patient-centred and culturally competent care.
RESULTS
Overall, content in these materials misrepresented and under-represented patients. Materials contained both outdated and unnecessarily sexualised language, in addition to a lack of patient diversity. Clinical authority was often centred over patient agency, and several updated PE techniques known to improve patient experience were absent. Patient-centred and culturally competent approaches were therefore inadequately highlighted in most of the materials.
CONCLUSIONS
Depictions contained in these materials may be perpetuating stereotypes and biases in medicine and may be working to maintain teaching practices that cause harm to patients (standardised and regular) who students interact with in both clinical and educational settings. Efforts may be needed to improve classroom materials on the PE so that they more adequately centre patients and provide opportunities to discuss culturally competent approaches to the procedure that (i) may not be covered in other parts of the PE curriculum and (ii) can reduce known health disparities.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
716-723Commentaires et corrections
Type : CommentIn
Informations de copyright
© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.
Références
Akseer R, Connolly M, Cosby J, Frost G, Kanagarajah RR, Lim SHE. Clinician-patient relationships after two decades of a paradigm of patient-centered care. Int J Healthc Manag. 2021;14(3):888-897. doi:10.1080/20479700.2020.1713535
Beach MC, Rosner M, Cooper LA, Duggan PS, Shatzer J. Can patient-centered attitudes reduce racial and ethnic disparities in care? Acad Med. 2007;82(2):193-198. doi:10.1097/ACM.0b013e31802d94b2
CMPA. When medicine and culture intersect. CMPA. 2014. Accessed October 21, 2021. https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/when-medicine-and-culture-intersect
Stubbe DE. Practicing cultural competence and cultural humility in the care of diverse patients. Focus. 2020;18(1):49-51. doi:10.1176/appi.focus.20190041
Oscarsson M, Benzein E. Women's experiences of pelvic examination: an interview study. J Psychosom Obstet Gynecol. 2002;23(1):17-25. doi:10.3109/01674820209093411
Yanikkerem E, Özdemir M, Bingol H, Tatar A, Karadeniz G. Women's attitudes and expectations regarding gynaecological examination. Midwifery. 2009;25(5):500-508. doi:10.1016/j.midw.2007.08.006
Demers AA, Kliewer EV, Remes O, et al. Cervical cancer among Aboriginal women in Canada. CMAJ. 2012;184(7):743-744. doi:10.1503/cmaj.110523
Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med. 2014;47(6):808-812. doi:10.1016/j.amepre.2014.07.031
Eichelberger KY, Doll K, Ekpo GE, Zerden ML. Black Lives Matter: claiming a space for evidence-based outrage in obstetrics and gynecology. Am J Public Health. 2016;106(10):1771-1772. doi:10.2105/AJPH.2016.303313
DeSantis CE, Siegel RL, Sauer AG, et al. Cancer statistics for African Americans, 2016: progress and opportunities in reducing racial disparities. CA Cancer J Clin. 2016;66(4):290-308. doi:10.3322/caac.21340
Gusmano MK, Maschke KJ, Solomon MZ. Patient-centered care, yes; patients as consumers, no. Health Aff. 2019;38(3):368-373. doi:10.1377/hlthaff.2018.05019
Epstein RM. The science of patient-centered care. J Fam Pract. 2000;49(9):805-805.
Boutin-Foster C, Foster JC, Konopasek L. Viewpoint: physician, know thyself: the professional culture of medicine as a framework for teaching cultural competence. Acad Med. 2008;83(1):106-111. doi:10.1097/ACM.0b013e31815c6753
Paasche-Orlow M. The ethics of cultural competence. Acad Med. 2004;79(4):347-350. doi:10.1097/00001888-200404000-00012
Sharma M. Applying feminist theory to medical education. Lancet. 2019;393(10171):570-578. doi:10.1016/S0140-6736(18)32595-9
Evans D, Goldstein S, Loewy A, Altman AD. No. 385-indications for pelvic examination. J Obstet Gynaecol Can. 2019;41(8):1221-1234. doi:10.1016/j.jogc.2018.12.007
Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(1):67-72. doi:10.7326/M14-0701
Almonte M, Ferreccio C, Winkler JL, et al. Cervical screening by visual inspection, HPV testing, liquid-based and conventional cytology in Amazonian Peru. Int J Cancer. 2007;121(4):796-802. doi:10.1002/ijc.22757
Rosa M, Pragasam P, Saremian J, Aoalin A, Graf W, Mohammadi A. The unsatisfactory ThinPrep® Pap Test™: analysis of technical aspects, most common causes, and recommendations for improvement. Diagn Cytopathol. 2013;41(7):588-594. doi:10.1002/dc.22904
Rashid NW, Josephson EB, Waseem M. Pelvic examination and wet preparation. In: Ganti L, ed. Atlas of Emergency Medicine Procedures. Springer; 2016:463-467. doi:10.1007/978-1-4939-2507-0_82
Hoyo C, Yarnall KSH, Skinner CS, Moorman PG, Sellers D, Reid L. Pain predicts non-adherence to pap smear screening among middle-aged African American women. Prev Med. 2005;41(2):439-445. doi:10.1016/j.ypmed.2004.11.021
Wijma B, Gullberg M, Kjessler B. Attitudes towards pelvic examination in a random sample of Swedish women. Acta Obstet Gynecol Scand. 1998;77(4):422-428. doi:10.1034/j.1600-0412.1998.770411.x
Areskog-Wijma B. The gynaecological examination-women's experiences and preferences and the role of the gynaecologist. J Psychosom Obstet Gynecol. 1987;6(1):59-69. doi:10.3109/01674828709023862
Peitzmeier SM, Potter J. Patients and their bodies: the physical exam. In: Eckstrand KL, Potter J, eds. Trauma, Resilience, and Health Promotion in LGBT Patients: What Every Healthcare Provider Should Know. Springer International Publishing; 2017:191-202. doi:10.1007/978-3-319-54509-7_16
Wendt E, Fridlund B, Lidell E. Trust and confirmation in a gynecologic examination situation: a critical incident technique analysis. Acta Obstet Gynecol Scand. 2004;83(12):1208-1215. doi:10.1111/j.0001-6349.2004.00597.x
Bodden-Heidrich R, Walter S, Teutenberger S, et al. What does a young girl experience in her first gynecological examination? Study on the relationship between anxiety and pain. J Pediatr Adolesc Gynecol. 2000;13(3):139-142. doi:10.1016/S1083-3188(00)00056-5
Gupta S, Hogan R, Kirkman RJE. Experience of the first pelvic examination. Eur J Contracept Reprod Health Care. 2001;6(1):34-38. doi:10.1080/ejc.6.1.34.38
Ackerson K. A history of interpersonal trauma and the gynecological exam. Qual Health Res. 2012;22(5):679-688. doi:10.1177/1049732311424730
Robohm JS, Buttenheim M. The gynecological care experience of adult survivors of childhood sexual abuse: a preliminary investigation. Women Health. 1997;24(3):59-75. doi:10.1300/J013v24n03_04
Güneş G, Karaçam Z. The feeling of discomfort during vaginal examination, history of abuse and sexual abuse and post-traumatic stress disorder in women. J Clin Nurs. 2017;26(15-16):2362-2371. doi:10.1111/jocn.13574
Dutton L, Koenig K, Fennie K. Gynecologic care of the female-to-male transgender man. J Midwifery Womens Health. 2008;53(4):331-337. doi:10.1016/j.jmwh.2008.02.003
Peitzmeier SM, Agénor M, Bernstein IM, et al. “It can promote an existential crisis”: factors influencing pap test acceptability and utilization among transmasculine individuals. Qual Health Res. 2017;27(14):2138-2149. doi:10.1177/1049732317725513
McCune K, Imborek K. Clinical care of lesbian and bisexual women for the obstetrician gynecologist. Clin Obstet Gynecol. 2018;61(4):663-673. doi:10.1097/GRF.0000000000000399
Chor J, Stulberg DB, Tillman S. Shared decision-making framework for pelvic examinations in asymptomatic, nonpregnant patients. Obstet Gynecol. 2019;133(4):810-814. doi:10.1097/AOG.0000000000003166
Tillman S. Consent in pelvic care. J Midwifery Womens Health. 2020;65(6):749-758. doi:10.1111/jmwh.13189
Carter S, Rad M, Schwarz B, Van Sell S, Marshall D. Creating a more positive patient experience of pelvic examination. J Am Assoc Nurse Pract. 2013;25(11):611-618. doi:10.1111/1745-7599.12020
Terri K. Public Privates: Performing Gynecology from Both Ends of the Speculum. Duke University Press; 1997.
Seehusen DA, Johnson DR, Earwood JS, et al. Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial. BMJ. 2006;333(7560):171. doi:10.1136/bmj.38888.588519.55
Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception. 2003;67(4):313-317. doi:10.1016/S0010-7824(02)00540-1
Arbyn M, Smith SB, Temin S, Sultana F, Castle P, Collaboration on Self-Sampling and HPV Testing. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018;363:k4823. doi:10.1136/bmj.k4823
Cerigo H, Macdonald ME, Franco EL, Brassard P. HPV dectection by self-sampling in Nunavik, Quebec: inuit women's sampling method preferences. Int J Indig Health. 2012;8(1):29-39. doi:10.3138/ijih.v8i1.29012
Gupta S, Palmer C, Bik EM, et al. Self-sampling for human papillomavirus testing: increased cervical cancer screening participation and incorporation in international screening programs. Front Public Health. 2018:6. doi:10.3389/fpubh.2018.00077
Reisner SL, Deutsch MB, Peitzmeier SM, et al. Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients. PLoS ONE. 2018;13(3):e0190172. doi:10.1371/journal.pone.0190172
Qin J, Saraiya M, Martinez G, Sawaya GF. Prevalence of potentially unnecessary bimanual pelvic examinations and Papanicolaou tests among adolescent girls and young women aged 15-20 years in the United States. JAMA Intern Med. 2020;180(2):274-280. doi:10.1001/jamainternmed.2019.5727
Silverman RE. Teaching those who teach to have a voice: the history and current practices of Gynecological Teaching Associates. J Med Pers. 2014;12(2):60-67. doi:10.1007/s12682-014-0177-2
Underman K. Feeling Medicine: How the Pelvic Exam Shapes Medical Training. New York University Press; 2020. https://books.google.ca/books?hl=en&lr=&id=mgS5DwAAQBAJ&oi=fnd&pg=PA1&dq=%22empathy%22+AND+%22pelvic+exam%22&ots=FJWprjOQqg&sig=pnigYo0asOchqZDZxarIrC2ykM8&redir_esc=y#v=onepage&q=%22empathy%22%20AND%20%22pelvic%20exam%22&f=false
Beckmann CRB, Lipscomb GH, Williford L, Bryant E, Ling FW. Gynaecological teaching associates in the 1990s. Med Educ. 1992;26(2):105-109. doi:10.1111/j.1365-2923.1992.tb00134.x
Beckmann CRB, Barzansky BM, Sharf BF, Meyers K. Training gynaecological teaching associates. Med Educ. 1988;22(2):124-131. doi:10.1111/j.1365-2923.1988.tb00422.x
Fairbank C. Effective teaching of pelvic examination. Clin Teach. 2009;6(2):101-104. doi:10.1111/j.1743-498X.2009.00274.x
Janjua A, Smith P, Chu J, et al. The effectiveness of gynaecology teaching associates in teaching pelvic examination to medical students: a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. 2017;210:58-63. doi:10.1016/j.ejogrb.2016.10.006
Shain RN, Crouch SH, Weinberg PC. Acquisition of pelvic examination skills: evaluation of student feelings about a surrogate patient program. J Psychosom Obstet Gynecol. 1983;2(2):65-70. doi:10.3109/01674828309081260
Wånggren K, Fianu Jonassen A, Andersson S, Pettersson G, Gemzell-Danielsson K. Teaching pelvic examination technique using professional patients: a controlled study evaluating students' skills. Acta Obstet Gynecol Scand. 2010;89(10):1298-1303. doi:10.3109/00016349.2010.501855
Steer M. Viewpoint of a gynaecological teaching associate from Canada. Br Med J 2003;326(97). https://www-bmj-com.proxy3.library.mcgill.ca/rapid-response/2011/10/30/viewpoint-gynaecological-teaching-associate-canada
Underman K. “It's the knowledge that puts you in control”: the embodied labor of gynecological educators. Gend Soc. 2011;25(4):431-450. doi:10.1177/0891243211415847
Hall JC. “Okay so remember, this is a drape-not a sheet”: a critical autoethnography of (per)forming the practice(d) body of a Gynecological Teaching Associate. 2012. https://ir.lib.uwo.ca/etd/863/
Wilson RF. Autonomy suspended: using female patients to teach intimate exams without their knowledge or consent. J Health Care L & Pol'y. 2005;8(2):240-263.
Friesen P. Educational pelvic exams on anesthetized women: why consent matters. Bioethics. 2018;32(5):298-307. doi:10.1111/bioe.12441
Friesen P, Persaud R, Wilson RF. Legislative alert: the ban on unauthorized pelvic exams. Social Science Research Network. 2020. Accessed June 22, 2021. https://papers.ssrn.com/abstract=3719496
Goldberg E. She didn't want a pelvic exam. She received one anyway. The New York Times. February 17, 2020. Accessed May 10, 2020. https://www.nytimes.com/2020/02/17/health/pelvic-medical-exam-unconscious.html
Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med. 2018;202:38-42. doi:10.1016/j.socscimed.2018.02.023
Martin GC, Kirgis J, Sid E, Sabin JA. Equitable imagery in the preclinical medical school curriculum: findings from one medical school. Acad Med. 2016;91(7):1002-1006. doi:10.1097/ACM.0000000000001105
Clarke AE, Friese C, Washburn R. Situational Analysis in Practice: Mapping Research with Grounded Theory. Routledge; 2016. doi:10.4324/9781315420134
Clarke AE. Situational analyses: grounded theory mapping after the postmodern turn. Symb Interact. 2003;26(4):553-576. doi:10.1525/si.2003.26.4.553
Perez MS, Cannella GS. Using situational analysis for critical qualitative research purposes. In: Denzin NK, Giardina MD, eds. Qualitative Inquiry and Global Crises. Routledge; 2016:97-117. doi:10.4324/9781315421612-5
Licqurish S, Seibold C. Applying a contemporary grounded theory methodology. Nurs Res. 2011;18(4):11-16. doi:10.7748/nr2011.07.18.4.11.c8630
Martin W, Pauly B, MacDonald M. Situational analysis for complex systems: methodological development in public health research. AIMS Public Health. 2016;3(1):94-109. doi:10.3934/publichealth.2016.1.94
Drisko JW, Maschi T. Content Analysis. Oxford University Press; 2016. http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=4310782
Hearn J, Dewji M, Stocker C, Simons G. Patient-centered medical education: a proposed definition. Med Teach. 2019;41(8):934-938. doi:10.1080/0142159X.2019.1597258
Snow R, Crocker J, Talbot K, Moore J, Salisbury H. Does hearing the patient perspective improve consultation skills in examinations? An exploratory randomized controlled trial in medical undergraduate education. Med Teach. 2016;38(12):1229-1235. doi:10.1080/0142159X.2016.1210109
Posner GD. The quandary of the sacred vagina: exploring the value of gynaecological teaching associates. Med Educ. 2015;49(12):1179-1180. doi:10.1111/medu.12889
Paul-Savoie E, Bourgault P, Potvin S, Gosselin E, Lafrenaye S. The impact of pain invisibility on patient-centered care and empathetic attitude in chronic pain management. Pain Res Manag. 2018;2018:e6375713. doi:10.1155/2018/6375713
Ho A. Trusting experts and epistemic humility in disability. Int J Fem Approaches Bioeth. 2011;4(2):102-123. doi:10.3138/ijfab.4.2.102
Lee BC, Grube D. Medical aid in dying: the cornerstone of patient-centered care. Generations. 2017;41(1):39-41.
Farrell RM, Nutter B, Agatisa PK. Patient-centered prenatal counseling: aligning obstetric healthcare professionals with needs of pregnant women. Women Health. 2015;55(3):280-296. doi:10.1080/03630242.2014.996724
Friesen P, Towle S, Perez T. Birthing alone: an ethical analysis of pandemic policies banning birthing partners. Int J Fem Approaches Bioeth. 2021;14(2):114-143. doi:10.3138/ijfab-14.2.08
de Labrusse C, Ramelet AS, Humphrey T, Maclennan SJ. Patient-centered care in maternity services: a critical appraisal and synthesis of the literature. Womens Health Issues. 2016;26(1):100-109. doi:10.1016/j.whi.2015.09.003
Wilcox HN. Embodied ways of knowing, pedagogies, and social justice: inclusive science and beyond. NWSA J. 2009;21(2):104-120.
Claramita M, Sutomo AH, Graber MA, Scherpbier AJ. Are patient-centered care values as reflected in teaching scenarios really being taught when implemented by teaching faculty? A discourse analysis on an Indonesian medical school's curriculum. Asia Pac Fam Med. 2011;10(1):4. doi:10.1186/1447-056X-10-4
Bellicoso E, Quick SO, Ayoo KO, Beach RA, Joseph M, Dahlke E. Diversity in dermatology? An assessment of undergraduate medical education. J Cutan Med Surg. 2021;25(4):409-417. doi:10.1177/12034754211007430
Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971-977. doi:10.1001/jama.2011.1255
Eckstrand K, Lomis K, Rawn L. An LGBTI-inclusive sexual history taking standardized patient case. MedEdPORTAL. 2012;8:9218. doi:10.15766/mep_2374-8265.9218
Sharma M. ‘Can the patient speak?’: postcolonialism and patient involvement in undergraduate and postgraduate medical education. Med Educ. 2018;52(5):471-479. doi:10.1111/medu.13501
Whitney K. Making bodies matter: norms and excesses in the well-women visit. In: Women's Health Advocacy: Rhetorical Ingenuity for the 21st Century. Routledge; 2019. doi:10.4324/9780429201165-11.
Loue S, Wilson-Delfosse A, Limbach K. Identifying gaps in the cultural competence/sensitivity components of an undergraduate medical school curriculum: a needs assessment. J Immigr Minor Health. 2015;17(5):1412-1419. doi:10.1007/s10903-014-0102-z