aamc.org does not support this web browser.
  • Viewpoints

    Teaching medical students to perform an often-dreaded exam

    Gynecological teaching associates (GTAs) use their own bodies to help students gain expertise in pelvic exams. Here’s why the job was so empowering for one GTA.

    Pamela Good, LMT, CPT
    Pamela Good, LMT, CPT, says serving as a gynecological teaching associate has been some of the most meaningful work she’s ever done.
    Courtesy: Pamela Good, LMT, CPT

    Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

    For over a decade, I did work that some people find a little shocking: I was a gynecological teaching associate (GTA) for medical students. And I confess that when I was first asked to do it, I was pretty taken aback myself.

    I was working as a standardized patient — someone who acts the part of a patient in various medical scenarios — at Eastern Virginia Medical School (EVMS) in Norfolk when my supervisor, Jean Bishop, suggested I become a GTA. “Um, GTA?” I asked.

    Jean explained that GTAs are lay people trained to teach medical students to perform pelvic exams and other aspects of gynecological visits. But here’s the kicker: They do so using their own bodies.

    A slight shock ran through me. “You mean we teach the pelvic exam using ourselves as the patient?” After she shook her head yes, I stammered, “Um, not so sure I can do that.” Jean reassuringly laid her hand on my arm and said, “You’re gonna find it’s some of the most rewarding work you will ever do.”

    It turns out she was right. Even now, having given up this work because I’m finding myself too old for it, I still miss the opportunity to contribute to medical education in this meaningful way.

    Sometimes, medical students learn to perform the pelvic examination by practicing on full-body manikins and small plastic models, but manikins are unable to provide feedback and plastic is not as elastic as real vaginal tissue. Students can learn to insert the speculum, for example, but their technique may be less than gentle. So GTAs act as patient and instructor, allowing students to practice necessary skills, receive real-time feedback, and adjust their technique accordingly.

    Medical schools increasingly appreciate the benefits of GTAs. In one survey of 100 medical schools, 70% reported using GTAs to teach pelvic and breast exams. GTAs also often help train numerous other providers, including residents, physician assistants, and the nurses who collect evidence and care for patients following a sexual assault.

    My career as a GTA began when I agreed to observe a demonstration meeting with Jean the following week. I hadn’t realized, though, that Jean’s infectious enthusiasm for her work would persuade me to actually perform the exam that day.

    Even as I agreed to perform the pelvic exam under Jean’s guidance, I carried deep anxieties about it. Past negative experiences with my own pelvic examinations affected me. And then there was the bigger question that I had to ask myself: Would I be able to handle this demonstration as a sexual trauma survivor?

    My trepidation was evident as I stepped into the room. Moira, our GTA for the session, quickly sensed and eased that anxiety with some humor — gentle, playful, and sensitive — as well as reassurances that she would ensure my success. Confidently and patiently, she led us step-by-step through the pelvic, rectovaginal, and breast exams. She used a number of tools to teach us, including illustrations, hands-on guidance, and demonstrations followed by our mirroring her techniques.

    It was while we were learning speculum insertion that I had my first glimpse of a cervix, and I caught myself involuntarily exclaiming, “Oh my gosh, this is so amazing!” I was a little embarrassed by my outburst and quickly apologized, but Moira just smiled and said, “Isn’t it?”

    I was in awe throughout the rest of the exam. As I watched my fellow learners have similar reactions, I thought, “Wow. Is this the same joy in discovery we can offer our students? Will they have this same remarkable sense of accomplishment we are feeling right now?” All anxiety dropped away, replaced by amazement and pride.

    When I left the exam room that day, I had no doubt that I would become a GTA and join a unique group: women who are committed to empowering students during one of the most dreaded but necessary exams for women's health, students who in turn will empower their future patients.

    Students become deeply aware that this “patient” is a human being — a human being who likely is afraid of the examination, who may be ashamed of her body, who may have suffered sexual trauma, and who may be re-traumatized by the examination.

    My training lasted roughly 50 hours spread throughout six weeks. It included a thorough understanding of the anatomy of the female reproductive system as well as such skills as how to palpate tissue during a breast exam, locate the ovaries, check for abnormalities, and test for sexually transmitted diseases. Throughout, we practiced on and supported each other.

    I became so fascinated and inspired by the work that I pursued other avenues to further patient care. I trained as an emergency medical technician, for example, while still teaching as a GTA. Many of my fellow GTAs also did this work part time while pursuing careers as teachers, social workers, actors, dancers, and more.

    At EVMS, GTA work usually happens in groups of two to four students, which enables lots of hands-on practice for each learner. During the pandemic, training went online for a while, but the program now has managed to restore the crucial in-person aspect of the work.

    When training students, EVMS made a few slight changes to the real-world gynecological examination. For example, to make it less overwhelming, our program breaks the pelvic exam down into its four parts — visualization and palpation of structures, speculum insertion and exam, palpation of ovaries and uterus, and rectovaginal exam — instead of having each student perform the entire exam all at once. Each part is practiced round-robin style, with a student first observing and then applying the medical techniques and communication skills involved.

    Throughout, GTAs discuss patient-centered language and approaches, and students have repeated opportunities to practice this “new” language during the exam. Students become deeply aware that this “patient” is a human being — a human being who likely is afraid of the examination, who may be ashamed of her body, who may have suffered sexual trauma, and who may be re-traumatized by the examination.

    Our students learn that using wording that sounds less sexual can make a difference — even if on a subconscious level — in helping calm a patient. So our GTAs teach them to use words such as “contact” rather than “touch” and phrases like “let the knees drop outward” rather than “open your legs.” We also stress patient education as a way to include and empower those we examine, with the student providing a mirror and naming the parts of the anatomy that are being palpated or observed.

    And GTAs also make sure to provide lots of empathy to any student who may be anxious about performing or who may have their own shame regarding this intimate examination. Many times, those same learners finish the session with tremendous gratitude. “It wasn’t as scary as I thought it was going to be,” they sigh in relief.

    Looking back on my years as a GTA, I recall so many moments in which I felt gratitude for the opportunity to do that work.

    There was the student who was so moved after performing the examination that they proclaimed, “That’s it, I am going into women’s health.” There was the student moving through her own shame surrounding the exam who bravely stepped up and performed first in the group.

    And there were the many times I witnessed students’ eyes light up — it never once got old — when they palpated a real human ovary. “Wow! That’s really it? It’s different than what I had imagined. That is so amazing!” they would say. At times like that, it was hard not to smile with them and think, “Isn’t it?”