Gynaecological teaching associatesBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7476.s212 (Published 20 November 2004) Cite this as: BMJ 2004;329:s212
They have been branded as hired prostitutes, lesbians and women do-gooders, but gynaecological teaching associates provide UK medical students with experience in gynaecological examinations and are being used in an increasing number of countries. Lucy Cowdrey finds out more
Three years ago, two family planning doctors decided to take action against the inadequate teaching of gynaecological skills at Guy's, King's and St Thomas' Medical School (GKT) in London. Paula Baraitser and Sally Pickard knew about the gynaecological teaching associate (GTA) system that had been operating for years in the USA, Canada, Australia, and Scandinavia, and wondered if the same structure could be applied in the United Kingdom.
GTAs allow medical students to perform bimanual pelvic and speculum examinations on them while giving constructive feedback on the students' communication and practical skills. During the examination, they can guide the students about what they are doing right or wrong. They also work with the students through role play, for example, how to sensitively explain and discuss the smear test and bimanual examination.
Part of the GTAs' training is to talk about their own personal experiences of going for smear tests, and the best and worst communications they have received from healthcare professionals. GTAs study different aspects of gynaecology for two months including studying diagrams and photos of normal and abnormal cervixes—although they do not teach students about the pathology.
Twenty five year old Paula Pheby, who used to work in IT, was one of six women selected to be trained as a GTA for the GKT scheme, after responding to an advert in her GP's surgery.
“We had a brainstorming session to develop a role play,” Paula said. “We shared our personal experiences of going for a smear test, and we felt that certain aspects could have been explained better. So it's important for us to work out the best way of communicating effectively.”
There was also some practical training. Initially the GTAs practised on every medical student's nightmare—the manikin. Then they had to perform examinations on each other with the help of a doctor.
“That was a really strange experience,” recalls Paula. “It seemed crazy that I was spending my Friday afternoons practising bimanual and speculum examinations on other women. I was also terrified about hurting someone with a speculum. I'd say it took about six months to feel completely confident in my examination techniques.”
Comparing the two different methods of examinations—practising on manikins and on real women—helped Paula realise the major discrepancies with conventional gynaecological teaching.
“The manikins are dreadful,” Paula explains. “They are completely inadequate for learning the technique. They are made of rubber—a very different consistency to a woman's vagina. You can't use lubricant on the manikins, and there is no pubic hair, which is an obstacle you have to deal with on real women. The cervix is not realistic and the bimanual is difficult to perform. But the main thing is that you can't communicate with a manikin. Students need to understand patients' fears and also understand how to educate them on smear tests. So they need to practise this on real women.”
She continues, “Some medical students were coming to the end of their reproductive and sexual health rotation without having performed a single vaginal examination. It's difficult to obtain consent from patients, particularly for male students, as they naturally feel uncomfortable about having a student examine them. With the GTAs, everyone gets an equal chance to practise their skills.”
The GTAs have become an important part of the curriculum at GKT and other medical schools. Teaching sessions involve two GTAs; one acts as a patient and the other demonstrates a bimanual and speculum examination, then supervises four students' examinations. Most women may feel squeamish at the thought of undergoing four speculum examinations in a row, and Paula admits that this can be something of a trial.
It all sounds very well meaning, but the process makes me and others cringe a little. I cannot exactly figure out why it should be any more uncomfortable than performing such procedures in clinic, but I have two theories—firstly, that such examinations are unnecessary and secondly, that we are subconsciously judging the GTAs.
In clinic it is acknowledged by both parties that a vaginal examination may be unpleasant, but is necessary for medical purposes. With GTAs it is only the student who benefits, similar to our practising cannulation or urethral catheterisation on a perfectly healthy individual—it all seems a little masochistic.
We should be grateful to these women who give up their privacy and devote their efforts to help students. These women together can produce a generation of doctors who perform routine smears more comfortably and benefit hundreds of women in years to come. They are modern day martyrs for women's health. But what kind of woman would volunteer to do this and what do they tell their friends they do for a living? It also has financial implications—$20 000 to teach 170 American students for one session.1
Using GTAs is only partially beneficial to students as these women all have normal anatomy. Students are only going to be exposed to a wider variety of pathology if women are more willing to be examined by students in clinic. Could this shortfall be tackled without GTAs and at a lower cost? The communication skills aspect of the session could be delivered by far fewer staff. The technical aspect could be dealt with in clinic and theatre, only if more female patients were willing to be examined by students. This would require a change in culture in the United Kingdom—not easily achieved but something to aim for.
Syed M A Sohaibfifth year medical student
Royal Free & University College Medical School, London
“I got thrush after undergoing 11 speculum examinations in one day, though this number of exams is unusual. We tend to rotate the roles, not just to give each other a break, but there are also practical issues such as women being on their periods.”
Her choice of job also leaves her friends incredulous. “To start with, I said I was a teacher, but I have told most of my friends and family everything now. People's initial reaction is to think that you must be round the bend, and it can put a real strain on your relationships.” She continues, “My friends get worried that the students laugh about me after the session. Others decide that I must be a lesbian and one woman friend stopped talking to me for that reason.”
People's initial reaction is to think that you must be round the bend, and it can put a real strain on your relationships
So why put herself through this? Paula explains, “It is very satisfying if a really nervous student comes to a session, and I can make them leave the session feeling confident and happy.” She also thinks that people are now generally more supportive. “I think most people now realise that I'm actually doing something valuable and are much more supportive.”
Even the harshest of sceptics would be hard-pushed to deny the overwhelmingly positive effect GTAs have had on gynaecological training. A study performed in their first year of practising at GKT showed that GTA trained students acquired significantly better skills that a conventionally trained control group.2 And medical students seem to prefer this method of teaching—with 99% of them thinking it worthwhile. There has been an explosion in the demand for their teaching services and the GTAs have recently set up their own business in order to cope with this. They are also asking the Royal College of Obstetrics and Gynaecology to recognise them as health professionals so that people will take them more seriously.