Medicine is blind to body diversity—and it’s limiting doctors’ examination skills
BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2591 (Published 07 November 2023) Cite this as: BMJ 2023;383:p2591
In my last year of medical school, I eagerly signed up to act as a patient on a point-of-care ultrasound course for emergency department doctors. My agenda, naturally, was to see my heart in action on an echocardiogram. My enthusiasm was quickly replaced by disappointment when I realised that female volunteers were being kept away from the cardiac stations. It was only when my request to swap midway was denied because “breasts make it harder to visualise the heart” that I recognised the magnitude of the problem.
In a room of healthcare professionals about to be certified as competent in point-of-care ultrasound, none of them were going to practise visualising the hearts of people with breasts. “But won’t half their patients be women?” I pointedly asked. I was granted the swap—and then spent all afternoon having my spleen, instead of my heart, scanned. Timid doctors, seemingly afraid to communicate the need to adjust the position of my breast to visualise my heart, instead pressed frantically into my ribcage. Soon, my chest felt bruised and sore.
Barely one physician demonstrated competence, let alone sensitivity, in examining my female body. As a doctor in training, I now wonder what proportion of echocardiogram reports that read “interpretation limited by technically difficult examination” might simply be referring to people with breasts.
Commentators have outlined the ways in which sexism pervades medical education.1 A 2022 study highlighted how women’s bodies are marginalised in the teaching of physical examination skills, resulting in students who aren’t confident or comfortable examining women.2 This aligns with my own experiences. I’ve seen clinical tutors routinely avoid the “complication” of teaching students how to perform cardiorespiratory examinations on women. At medical school I overheard students express frustration over the inclusion of female patients in objective structured clinical examinations (OSCEs), as they knew that exposing their chest may take more time and sensitivity. Comments like these went unchallenged and reflect how tolerant medicine is of the casual dismissal of women.3
Yet if medical students are not taught how to examine women then, by definition, our cases do become more “difficult.” The exclusion of women from clinical teaching vignettes is perpetuated, and sexism masquerades as pragmatism.
Not just women
But it’s not only women who find that their bodies and physical needs are sidelined in clinical interactions. I’ve seen medical professionals in consultations with people with physical disabilities direct their questions to care assistants or family members, seemingly oblivious to the person they’re treating. I doubt it’s malice that underpins these scenarios, but ignorance and embarrassment. My cohort of medical students were never taught how to manoeuvre stethoscopes around breast tissue or how to examine a person using a wheelchair. Indeed, I cringe recalling the time I first clerked someone with an amputation, having no idea of what words were inclusive as I examined them.
Yet for some patient groups, it’s not just a question of how the examination is performed, but if it will even be offered. A study from 1993 found that female patients with larger bodies are less likely to receive pelvic examinations.4 Throughout my training I have witnessed how the “othering” of people with larger bodies continues.567 For example, during a women’s health block, consultants considered speculum examinations of these women “too challenging” for trainees to carry out.
Inclusive teaching
Redressing the omission of diverse body types from examination teaching will help us to reliably elicit the clinical signs that are crucial to diagnosis. But it will also strengthen doctor-patient relationships—an inclusive physical examination enhances trust and patients’ feelings of being cared for.8910 So, what can be done? Educating medical students and doctors about the one-size-fits-all precedent in medicine is a foundation, but we must continue to diversify our medical school curriculums.
Educators have made a start11 in the examination of skin conditions after the Black Lives Matter movement added momentum12 to concerns about the lack of representation of darker skin tones in dermatology teaching. Yet the patients who feature in vignettes are still typically able bodied, white, heterosexual, slim, middle aged, and cis-gendered so we have some way to go.
Patient voices and advocacy should be incorporated into examination teaching to provide a platform for the experiences of marginalised people and to familiarise doctors with treating a range of patients.
It’s important that examination skills are taught in environments where trainees can learn from their mistakes. One of the most valuable and supportive teaching sessions I’ve ever participated in was one I was most apprehensive of: performing genital examinations. We practised with experienced volunteers who acted as facilitators, providing us with individual feedback in real time, which demystified intimate examination and instilled confidence.
Medical educators should apply the same approaches they use for teaching communication skills to physical examinations. When taking a patient’s history, we’re taught to respond to their cues, using them to adjust the structure, content, and tone of our conversation. Yet for physical examinations we are given a singular routine that we must robotically perform in our OSCEs, or risk losing marks.
Above all, physical examination teaching should be centred on consent. A lack of this fundamental principle was exemplified to me at medical school when my male peers were plucked out and asked to remove their shirts so that we could practise cardiorespiratory examinations. Their reluctance and embarrassment was often palpable, and yet demonstrators failed to acknowledge this. Obtaining true consent and responding to body language should be at the core of how physical examinations are taught. The lack of regard shown for my peers by qualified doctors is telling of how far the culture in medicine must shift to achieve truly patient centred care during physical examinations.
Tackling these gaps in training isn’t just a gesture of inclusivity—it’s about patient safety. What if I hadn’t been examined as part of a training session, but had presented to the emergency department with underlying cardiac pathology? I might have received a point-of-care ultrasound from a practitioner not clinically competent to scan a person who didn’t look like the male models they’d practised on, and I might have been sent home, without a diagnosis.
Footnotes
Competing interests: none declared.
Provenance and peer review: Not commissioned; not peer reviewed.