Medical schools should create policies that protect students and increase women’s comfort with peer-to-peer examination, argue Gurdas Singh, Sofia Weiss Goitiandia, Daisy Perry, and Jessica Spiers
One way of teaching medical students how to examine patients is peer-to-peer examination. This is learning how to examine patients through practising on your peers. Peer-to-peer teaching offers a number of advantages, including addressing the shortage of real patients available for examinations; allowing students to develop a sense of what it feels like to be examined; and developing an understanding of normal anatomy, which can be a useful reference point for how anatomy affected by disease differs. While this type of teaching is intended to provide a safe environment to practise examination, female medical students are likely to be less comfortable than male students with being examined by either male or female peers.
Given that approximately 51% of the UK population—i.e. our patient population—is female, and that as of 2017, 55% of UK medical students are women, providing a robust framework for learning how to examine female patients should be at the forefront of curriculum delivery for all medical schools. The anatomy of men and women is, of course, substantially different; therefore, it is important that medical students receive sufficient practice in examining both.
In our experience, it is a regular occurrence that during peer examination sessions male medical students are expected to assume the role of patient, especially for practising procedures such as ECGs, where the patient is expected to remove the top half of their clothing. During our medical training we have all been in multiple peer-to-peer teaching settings where female medical students were less willing to be examined than male students—and on some occasions have even been denied the opportunity to volunteer to be examined by facilitators. It’s also common knowledge that the patients presented in clinical examinations for medical students are more likely to be men—again, particularly for examinations that require the removal of clothing.
Why might this be the case? As medical students, three out of four identifying as female, we suggest that a key concern might be whether our bodies will be treated with the respect that they deserve. We live in a culture that objectifies the female form, arguably more so than it does the male, and it can feel as if a physical examination is yet another opportunity for scrutiny. In addition, body image concerns are unfortunately common in women, and so again, the idea of being physically examined can be especially frightening.
Developing the skills required to examine women must take place in an environment where the women being examined feel safe and respected. To achieve this, we need to address the issue directly, and create effective policy that protects students and increases women’s comfort with peer-to-peer examination. If we are able to do so, we will increase the chances that the doctors of the future can examine women with greater experience, knowledge, and respect.
We believe that the issue of examining women needs to be separated from the sexualised narrative that we as a culture are exposed to by the media and advertising. Medical students should be aware of the pressures female patients and peers might feel and respond with a degree of maturity that is reflected in the physical examinations that we deliver. To be clear, this does not mean that we should intuitively know how to perform physical exams on women, rather that we should be able to learn—and make mistakes—while behaving professionally, even if the person we are examining is a peer.
We propose that all students, regardless of gender, should be provided with information about what this teaching method involves and how to prepare for it, as well as a formal consent form for practice examination. Though medical schools in the UK expect a general written agreement from students that outlines standards of professionalism, we know that instances of unprofessional behaviour still occur. A specific, formal, written agreement of professional behaviour should be a prerequisite for consent immediately prior to peer-to-peer teaching sessions. Such a document should be created and monitored by the faculty overseeing the examination, and signed by the student performing it. This will ensure that the guidelines to abide by for this particular method of examinations are explicit, and fresh in the students’ minds.
There is already evidence from a study by the University of Auckland that when policies like these are adopted, students of both genders feel more comfortable. In fact, the researchers reported that a formal consent process for peer-to-peer teaching was “felt to be worthwhile by students and ensured that the scene was appropriately set.” Of course, the introduction of any form should not make being examined obligatory; the purpose would be to support informed consent to be examined, not to replace consent.
While outlining what is to be expected and gaining explicit consent is a good start, the experience of examination must then match any “promises” made. For the protection of those being examined, there needs to be clear guidelines about the appropriate course of action to be taken in cases where expectations are not met, and all claims of inappropriate behaviour should be dealt with both seriously and promptly by the relevant medical school and escalated where appropriate.
These suggested policies are not specific to women, but we believe that they would increase security with, and hence the uptake of, the practice of being physically examined by all students of all genders, including women. Hopefully, this would go some way to redressing the balance between male and female students that engage with the peer-to-peer model of physical examination.
Gurdas Singh is a medical student at the GKT School of Medical Education, King’s College London. Twitter: @Gurdas2209
Sofia Weiss Goitiandia is a medical student at the School of Clinical Medicine, University of Cambridge. Twitter: @SGoitiandia
Daisy Perry is a medical student at the GKT School of Medical Education, King’s College London.
Jessica Spiers is a medical student at the GKT School of Medical Education, King’s College London.
Competing interests: We confirm that we have all read and understood BMJ policy on declaration of interests and declare that there are no competing interests for any of the authors.