For Yukiko Asaki, it started with finding an appropriate outfit. Not too formal, but something conservative and professional. She hadn't really been looking forward to this Saturday morning experience, but accepting that there would be "certain level of awkwardness that could not be removed," she put on a button-down blouse, got into her doctor mode, and headed to the empty clinic at her medical school in New York City, where she would learn how to examine an unavoidable part of the human body: the privates.
Yukiko's medical school, like many in the country, participates in a unique way of teaching medical students the genitourinary exam. Instead of allowing students to practice on anesthetized women after a surgery, as is often done in other countries, the school hires Genitourinary Teaching Associates, or GUTAs, who instruct students on how to perform this sensitive examination using their own bodies. Your doctor who has seen "a million of those," may have seen his/her first one of "those" on a GUTA. And chances are it was one of the most nerve wrecking experiences of your doctor's training.
But Yukiko, who was 24 years old that spring morning of her second year of medical school, wasn't nervous yet. "I remember specifically that I'd always been interested in women's health, and it was important to me not only to learn how to do the [gynecological] exam but how to do it well. I wanted to do it sensitively, and conscientiously." She watched carefully as two female GUTAs acted out a script between doctor and patient, and then demonstrated proper examination techniques on each other.
She took note of such tips like telling the patient, "I am now going to examine your breasts," instead of saying "I am now going to look at your breasts," a statement that could easily make a woman uncomfortable. For almost 30 minutes, she paid attention in that warm, crowded examination room, trying to remember the steps of the examination as it was being demonstrated. "I was like, 'Keep it together, Asaki!' in my mind."
The adage in medical school is "see one, do one," and now it was Yukiko's turn to do one. "You can't really prepare yourself for how incompetent you going to feel when you actually have to do it," said Yukiko, whose laughter and candidness seem reliable indicators of her potential as a future physician. It was noticeably warm in the room, but now, faced with her instructor -- a tall, "stick thin" woman in her mid-20s with short brown hair and an aversion to shaving -- it was Yukiko's turn to pretend to be a physician. "At that point it got really hot in the room," and as she remembers it, her instructor was particularly unforgiving. "When we were doing the actual pelvic exam, she told me repeatedly I was not doing it correctly, and rather than tell me how to do it better, she just said, 'You're just not making this comfortable for me,' and I thought that was remarkably unhelpful." She tried her best to follow the steps of her instructor, but feeling no liberty to question the process (it was, after all, her instructor's body, and she couldn't very well argue about what to do with it) and little knowledge on how to perform the exam, she felt trapped. With no windows for a breeze, the door shut, her heavy white coat, and the naked women in stirrups scolding her, Yukiko's first encounter with female private parts was what she calls, "the single most awkward day of medical school. I've never wanted to leave a situation more than I've wanted to leave this one. Mercifully, it was over at some point."
The GUTAs witness medical students in their most anxious moments, and while not all of them may be as harsh as Yukiko's instructor, all GUTAs are taught the importance of carefully guiding the students who are touching their bodies. But the very act of touching the body, the bread and butter of medicine, is something that many medical students are uncomfortable with at the time they learn the genitourinary exam, which is usually before students start working on the wards. "You know, this was not two years into medical school yet, and I still had that residual feeling of not really belonging," said Yukiko. The ease with private parts is not acquired overnight, and between her sweat and her nerves, Yukiko's experience may very well be the norm.
"I did wonder about the people who were volunteering for this," said Yukiko, who remembers asking herself, "How does one find themselves in this line of work?" For John J. Steven Cole, 54, it was more of a natural progression. As an actor, he'd started making $17 on the side by working as a Standardized Patient at the Johns Hopkins School of Medicine in Baltimore, where he'd pretend to have various medical complaints for students to investigate. After almost a year of feigning stomach, chest, and joint pains and receiving positive feedback from students, Cole was asked if he would like to earn $55 to $60 an hour teaching medical students to do the genitourinary exam using his own body. "Initially, it was awkward in the training because I had never done it. I didn't know what the structure was. We had to instruct on ourselves and turn it over to student one, and then student two, and then student three, the whole way down the line," said Cole, who had prior experience teaching theater to aspiring actors. Over time, however, he viewed himself more as a medical educator helping train future doctors, than a naked man standing in front of nervous students. "That was a very powerful program, because you truly are the instructor."
The chance to teach students sensitive ways of approaching the genitourinary exam, to catch them at tabula rasa and infuse the exam with sympathy and compassion, lures many GUTAs to the job in the first place. Later in the day, when Yukiko was called to learn and perform the male genitourinary exam, practicing on a naked man in his mid-30s wearing a blue hospital gown and white tube socks wasn't nearly as distressing. "I did feel a little desensitized by that point, and I did feel comfortable." Her instructor told the students that two male members of his family had had breast cancer, and that participating in this program was his way of making sure that future doctors were always providing thorough care. Although it is not part of the male examination, he made each student perform a male breast exam on him. "It really wasn't as awkward as I thought it was going to be. I guess the easy answer is 'Oh, it was weird,' but it wasn't that weird." It also wasn't as warm.
Asking fresh medical students to push aside all former notions about private parts and to view them professionally is the expectation in medical school, and studies have repeatedly shown that using the GUTA has helped to not only demystify the exam, but also to teach students greater awareness of their word choice. The GUTA also carries the added bonus of preventing hoards of medical students from poking at every unwitting patient who enters the hospital, something that patients and students alike can appreciate. And for Yukiko, who will be starting her pediatrics residency this summer, the experience with her GUTA will always remain one of the most memorable, albeit sweaty, steps toward doctorhood. "I mean, I think at the end of the day I don't know that there's a better way to do it. I mean, I think it's a good approach. I can get over a little awkwardness."
Hawkins, Richard, et. al., of Standardized Patients for Teaching and Evaluating the Genitourinary Examination Skills of Internal Medicine Residents, Teaching and Learning in Medicine, Volume 10, Issue 2, April 1998, p. 65- 68
Robins, Lynne S., et. al., The Effect of a Standardized Patient Instructor Experience on Students' Anxiety and Confidence Levels Performing the Male Genitorectal Examination, Teaching and Learning in Medicine, Volume 9 Issue 4, October 1997, p. 264- 269
Andre Picard, "Time to end pelvic exams done without consent," The Globe and Mail, January 28, 2010