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.