My hospital day was cancelled today due to a impending snowstorm. I don’t have time to be disappointed since I have a final exam on the lungs, a.k.a. “pulmonary,” Friday morning. I’m home studying in my favorite spot (the couch), and it’s time for an update about something exciting… pelvic and breast exams!
Last week we had a special 4-hour evening session for Physical Diagnosis entitled “Breast and Pelvic.” Like many PD sessions, we weren’t given a lot of information ahead of time. We were asked to sign-up in groups, and then sent a reminder e-mail with two bullet points.
*Professional dress, white coat and name tag are required. You will be given a syllabus at the orientation…
*Personal appearance and demeanor are important. A pleasant appearance and polite approach demonstrate respect for the patient and encourage trust. Careful consideration should be given to grooming, with special attention to hands and nails… Examine hand jewelry for risk of injury to the patient or risk of exposure to the examiner through puncture of a protective glove.
Needless to say, my classmates and I were wondering what would happen. I did not feel nervous since I already assisted with many papanicolaou smears and three male GU (genito-urinary) exams. Also, I have experience as patient, having received annual pelvic and breast exams. These exams are not only important, but they are especially sensitive for women, so learning warranted a specialized session.
I was surprised to discover that the male exam was not covered in this session, and we will not have a dedicated session for males. This means that I will have to learn on the plastic models or by following doctors’ examples, and reading texts. While the male exam is supposedly “easier,” I have reservations about my first attempt at any procedure being in an exam room with a real patient.
I am reminded of a family friend whose daughter had brain surgery as a toddler, and the surgeon allowed a rotating medical student to do part of the suturing. When she lifted up her hair to show me the scar, I immediately knew which side the medical student sutured. It makes me cringe to think that I could be that medical student whose first attempts could figuratively or literally leave patients scarred for life. I would rather have good practice before I’m asked to do something, so I can proceed without as much fear and worry.
Therefore, I was thrilled with the woman who helped us learn the pelvic exam. I’ll never forget her. She was bubbly, talkative, and natural about the entire process. She was a good teacher who knew how to keep the atmosphere relaxed while giving us straight-forward instructions and feedback. I also appreciated that she had us help and observe one another since team-work is such an important, and often overlooked, lesson of medical training.
The breast and pelvic exam we were taught included more than I have witnessed or experienced before. Step 1 was the vaginal exam with a speculum. This included going slowly, using proper draping, helping the patient get into the right position, and explaining my movements. “You will feel my hand on your thigh. Now I’m examining the mons, labia… everything looks healthy. Now I’m going to insert the speculum.” It’s important to know how to hold the speculum, so it won’t pinch the skin, and insert it at a downward angle away from the urethra and clitoris. Then, once inside it hits resistance, and then is pulled back a little before opening slowly. Ideally, I would open it and the cervix, like a little mini-donut, would be right there, but often the cervix is at a different angle or to the left/ right. Then, on the way out the walls of the vagina are observed.
Step 2 was the bi-manual exam. This is where you put one or two fingers inside the vagina, then twist and press up on the bottom of the cervix. With your other hand, you feel the abdomen to locate the uterus and ovaries. For me, this was the trickiest part of the entire exam.
Step 3 was the vaginal-rectal exam. This is the part that I have never seen or experienced before. Apparently it is part of the “normal” exam, but it seems not many doctors actually do it unless they suspect a problem with the rectal wall. In this exam, the index finger is inserted in the vagina and the middle finger in the rectum. Those two fingers are swept left and right to feel for polyps or prolapses.
Then there is the breast exam. Like many physical exams, I was taught to observe first. We were told to ask the patient to raise their arms, then put them on their hips and move their shoulders forward. Then the patient lies down and we have to properly place a pillow to make them comfortable. With one arm raised, we palpate all the breast tissue using the preferred “lawn-mower” (I’d rather say “ zig-zag”) technique. And for bonus points, we should ask the patient about self breast exams.
When my group was almost complete with the session, one male classmate was left to finish the breast exam. He gave our standardized patient instructions to raise her hands, and then without thinking he said “Awesome.” She immediately told him that one should never say “awesome” during the breast exam. We all had a good laugh! Additionally we were told to stay away from phrases including “touch,” “feel,” “rub,” “stick” and “put.”
One of my favorite parts of medical school training has been working with standardized patients. I was astounded by how well this patient knew her body. Equipped with only a small mirror, she told us detailed information about where to look and what to see. I also have access to a skills center with large “life-like,” anatomical, blinking, and talking manikins, but nothing is more helpful for practicing procedures than a real human being. And nothing is better than an educated standardized patient who can make an awkward situation seem relaxed and even, dare I say it, “awesome.”
Posted by Liz 
