Doctors should be taught physical examination skills that are inclusive of all patients, says Joy Hodkinson
“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. 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. 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.
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. Throughout my training I have witnessed how the “othering” of people with larger bodies continues. For example, during a women’s health block, consultants considered speculum examinations of these women “too challenging” for trainees to carry out.
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.…
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.”
SOURCE: BMJ Opinion, by Joy Hodkinson. Vol.383, 7 November 2023, p.2591. DOI: https://doi.org/10.1136/bmj.p2591