By Jen Busse, MPH, RN, who is currently working as a nurse while studying at Columbia University College of Nursing to be a family nurse practitioner. She’s also an intern at the Center for Health, Media and Policy at Hunter College in New York City.
As I walked toward the school of nursing’s skills laboratory, my hands were sweating and my heart pounded. Today was the day of nurse practitioner school when I would learn how to perform a pelvic exam—on a living person. What if I couldn’t find the cervix or said the wrong thing? Or, worst of all, what if I hurt someone?
I peered through the door and a group of women looked over and welcomed me in. Other students began coming into the classroom, which was set up with 10 or so exam tables surrounded by hospital curtains. We were split into groups of threes, with two instructors each: our gynecological teaching associates (GTAs), or “pelvic models.” My hands shook uncontrollably now. As an RN, I’ve had numerous experiences with patients in potentially uncomfortable situations, such as placing Foley catheters or giving complete bed baths. But this just didn’t seem the same; somehow, it’s more personal.
With two of my classmates I approached the exam table. Our two GTAs were there, one sitting and the other standing, both smiling warmly. The area was already set up, intimidating metal speculum and all. One of the GTAs skillfully walked us through the exam while the other acted as a patient. Her actions were slow and deliberate, with special attention paid to ensuring that her “patient” felt comfortable and in control of the situation. She encouraged us to “empower” the patient by having her pull back the sheet for the exam on her own and then hold a mirror to better be a part of the examination. She stressed that the places where the patients placed their feet were not stirrups, but foot rests.
I was asked to go first. I practiced meeting my patient, asking about previous pelvic exams, and explaining to her the five-part gynecologic exam. It was made very clear that we were never to use language that could make a patient feel uncomfortable, and that all patients have the right to a thorough and judgment-free examination—excellent points about how health care should be, but often isn’t.
My hands shook and the metal speculum rattled as I showed my patient how it worked. I was then instructed to allow her to manipulate a demonstration speculum for herself. As the time for the exam grew nearer, my GTA met my eye and I said, voice shaking, “I’m just a little nervous.” She replied, “Well, if you weren’t nervous, I would have to be!” We all laughed, and I began to relax.
The rest of the exam went off without a hitch. My nerves settled as I was expertly guided to identify a retroverted uterus and other normal findings among the pelvic structures. They corrected us when our palpations were performed inaccurately, or when we told a patient that “everything looks fine”—when really we should have stuck to neutral medical terminology and said “everything looks normal.” Words like “fine,” it was pointed out, can be thought of as complimentary, and make a patient feel uncomfortable, or they might be construed as unclear, which may leave doubt in the patient’s mind.
The most valuable part of this experience was having the patient as a teacher. Only they are able to enlighten a provider about what hurts or about language that makes them feel uncomfortable. Often, the focus in nursing and medical training is so much on searching for some pathology that we lose sight of provider–patient rapport and patient comfort. The 15 other patients we must see in the next three hours loom too prominently in our minds, at the expense of patient-sensitive care. The GTAs highlighted the importance of a respectful and sensitive patient–provider relationship—which in turn allows for more trust on the part of the patient, a more thorough and accurate exam, and a better experience for all.
Wow, I sure wish that I had had such support when I learned to do pelvic exams. I had a neonatal background and had had severe endometriosis, with all that brings, so it was very difficult for me. When I finally had my first find (the cervix!) I was doing the exam on a fellow nurse and she was just so fantastic. I gasped, she laughed and all my qualms were swept away.
I am reminded of a pelvic exam I encountered so many years ago. I had always been “tender” with pelvic exams, in fact they were very painful for me with residuals that lasted up to 48 hours. When I mentioned this to my “female” examiner I was told to “shut up and take it like a woman” and that she was a woman and since she had never experienced this problem and knew all there was to know about women’s anatomy, it was “all in my head.” Ms. Busse has illustrated how far we have come in how we see the patient, how we listen to the patient and how we involve them in their healthcare. And kudos to her for understanding the importance of that involvement in our ability to provide quality care.
Thanks for the post, I am a nursing student and my physical exam test is this week and soooo nervous. Thanks for sharing that even though we get nervous we can still perform our duty to serve others.
Thanks for the post. I agree with Barbara Glickstein’s comment, “Women deserve excellent health care and that includes maintaining a right to language that is appropriate and respect for their dignity.” I would like to add that in some NP and CNM programs the students have to be pelvic models for each other. Not only is this an invasion of privacy, but I think the students could miss out on some of the valuable feedback they might receive from a neutral model, as opposed to a classmate.
This post brought back a flood of memories of my life in the late 1970s engaged with the early days of the women’s health movement as a feminist health activist. One action that we took on was just what Ms. Busse so beautifully talks about in her post – that we could prepare a team of informed powerful women to educate the mostly all-male physicians (back then) how to do a pelvic exam. The movement took off slowly in the trenches of one woman one gyn exam grass roots movement. Women shared their stories in consciousness raising groups and then individual woman talked to their practitioner asking that they put a heating pad under the drawer that stored the metal speculums and for a hand mirror to hold so she could see her (heaven forbid!) cervix. Women also learned from self-help groups that a “tilted uterus” wasn’t a death sentence. In the 1990s, Virginia Reath, PA, MPH and I co-hosted a women’s health radio show on public radio and dedicated one segment talking the listeners through each step a woman should expect out of a proper well done preventative gyn exam (we even brought in the roll of paper that covered table tops that invariably got stuck to your bottom when getting off the table). We opened up the telephone lines for listeners to call in. The phone board lit up with mostly all men callers shocked to hear what women go through, they had no idea. One man said he would be more supportive of his partner who started to have anxiety days leading up to her yearly gyn check-up. Glad to hear from Ms. Busse she benefitted from being taught by these well trained pelvic models. Women deserve excellent health care and that includes maintaining a right to language that is appropriate and respect for their dignity.
Barbara Glickstein, RN, MPH, MS