The Rise of the Gynecological Teaching Associate
Alexandra sets up her space in the small exam room. She puts her own pillow on the red table, then lays out a stack of disposable blue underpads known as “chux.” She wears comfortable socks. She is a little discombobulated—a colleague fell and broke her hip, so today, instead of 8 students, she’ll have 16. Each will practice one breast and two pelvic exams on her body. She remains upbeat. “People always think it’s going to be worse than it is for me.”
Alexandra is a Gynecological Teaching Associate, or GTA. She teaches student healthcare providers how to perform comprehensive breast and pelvic exams using her own body as the model. While GTAs may come from diverse backgrounds and most work on a contract basis supplementing other income, Alexandra has devoted herself to the field. After working as a GTA for several years, beginning in college, she founded a company to provide clinical skills training courses, including GTA sessions, to medical, advanced practice nursing, and physician assistant programs.
The students knock tentatively, and she welcomes them into the room. These are student nurse practitioners in a Family Nurse Practitioner program. All are registered nurses, and all have worked for some period of time at the bedside and have performed many physical examinations. Still, their nervousness is evident from their quiet voices and clasped hands. Alexandra sits upright on the exam table and introduces herself and the session. “I promise,” she says seriously, “I will not let you hurt me.”
Her words are carefully chosen. When people speak of their experiences as patients receiving pelvic exams, they tend to use adjectives like "uncomfortable," "painful," "embarrassing," or even "traumatic;" they might not be aware that their discomfort is often shared, to some degree, by the person performing their exam.
A 2015 study highlighted the anxiety that medical students feel when they learn how to do gynecologic examinations, identifying their primary worries as “forgetting steps,” “knowing normal from abnormal,” “appearing incompetent in front of the patient,” “being embarrassed or embarrassing the patient,” and, crucially, “hurting the patient.”
Not much has changed since students made a similar list in 1979, though then they also worried about sexual arousal and "disturbance of the doctor patient relationship." That disturbance is the point of the GTA, Alexandra explains. "[The provider has] to look to the person on the table for all the knowledge and authority." The GTA upends the traditional power dynamic and creates a bridge between the nervous student provider and the nervous patient.
“The GTA upends the traditional power dynamic and creates a bridge between the nervous student provider and the nervous patient.”
That bridge has been a long-time building. In 1975, a physician named Joni Magee published her "supine ruminations" from her own pelvic exams. She recalled fighting her urge to kick the doctor who shook her hand while she lay on the exam table, "perineum exposed to whatever breeze might have been stirring."
"Introduce yourself to your patient while she is still sitting up, preferably clothed," she admonished her fellow practitioners. "She'll feel much more human and happy." Among her other recommendations: "For your patient's sake, talk! Tell her what you're going to do before you do it," and, when placing a speculum, move "slowly. Very slowly."
Magee's article probably felt much like a cold breeze on the perineum to many of her colleagues, who had only recently begun to think about the autonomy, much less comfort, of either students or patients in the exam room. At the 1964 American Medical Association (AMA) meeting, the chairman of the Section on Obstetrics and Gynecology praised “the rediscovery . . . that patients are people . . . that the female genital organs are part of a woman.” In light of this unsettling recognition, and under pressure from both Women's Health Movement activists and increasing numbers of female medical students, medical schools began to re-evaluate how students were taught to care for both women and their genital organs.
The pelvic exam was originally devised in the 19th century and practiced— brutally—upon the bodies of enslaved women, Irish immigrants, and sex workers. When the exam became routine for purposes ranging from cancer screening to sexual surveillance, medical students learned to perform it directly on patients. In the 1960s, seeking to provide a less nerve-wracking learning experience for the student (and, by extension, the patient who would undergo that student's first examination), instructors began to introduce plastic pelvic models—punnily named "Gynny"—into the classroom.
Neither actual patients (whether unconscious or simply uncomfortable) nor plastic pelvises were in a position to provide much in the way of feedback. To address this challenge, Dr. Robert Kretschmar hired an anonymous nurse to serve as a live pelvic model for students at the University of Iowa in 1968. However, he found this setup "did little to enhance communication," and so over the following decade developed the first GTA program, with "professional patients" acting as "both patient and instructor." Across the country, other programs were beginning similar experiments; some hired sex workers, others relied heavily on graduate students. In 1975, female medical students from Harvard asked the staff of the feminist Women's Community Health Center to take over instruction of pelvic examination in their program. Over the next year and a half, these feminist activists created, revised, and then, on the grounds that it was not radical enough, torpedoed the Pelvic Teaching Program.
GTA programs have since become commonplace in medical and nurse practitioner programs nationwide but have not fully replaced older models. One common practice, which receives occasional outraged attention in the press, is student examination of gynecologic surgery patients under anesthesia, without explicit consent. While pelvic exams are sometimes a medically necessary part of the pre-surgical procedure, patients generally do not realize that they may be examined by not only the surgeon but by one or more medical students. In 2011, the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion stating that "if any pelvic examination planned for an anesthetized woman offers her no personal benefit and is performed solely for teaching purposes, it should be performed only with her specific informed consent, obtained before her surgery."
The same document acknowledged that patients at teaching hospitals and community clinics, who are disproportionately people of color and low-income individuals, are more likely to bear the brunt of a student's learning experience. Dr. Joia Crear-Perry, an OB/GYN as well as founder and President of the National Birth Equity Collaborative, recalled that when she trained in Louisiana in 2001, "One hundred people would show up at 8a.m. . . . The med student introduces themselves, the resident talks [them] through [the exam] . . . the framing around the free care was 'that's what they deserve' . . . that was where I realized the idea was that poor people were there for you to learn."
While ACOG's 2011 statement asserted that "race, ethnicity, or socioeconomic status should not be the basis for the selection of patients for teaching," it fell short of suggesting any systemic changes that would prevent the burden of providing a learning experience from continuing to fall squarely on the pelvises of poor people and people of color. As an ethical alternative, however, the ACOG statement noted the existence of GTAs.
“Yet providers who are trained by GTAs to view the patient as their partner may be less likely to abuse their medical authority in such ways.”
Alexandra supports this corrective approach. She teaches providers to work in partnership with their patient; she calls it "patient-directed" rather than "patient-centered" care because "in order to center something, it has to be still." One of the keys to improving the patient's experience in the examination room, she says, is to improve the attitude of the provider about the examination. She refers to a study that found people's impressions of others improved when they held a warm coffee cup: "Your brain crosses the wires of 'warm and comfortable' [and] 'person.' . . . [GTAs] are [the student's] first encounter with this: we are positive, we're comfortable, we normalize this, we're the authority. We are the coffee cup to set how they approach these exams for the rest of their careers."
There remain, of course, structural injustices linked to pelvic examination that a GTA cannot solve directly, including persistent overuse and misuse of the exam itself. Yet providers who are trained by GTAs to view the patient as their partner may be less likely to abuse their medical authority in such ways. One such provider is midwife Stephanie Tillman, who recalled the GTAs she trained with as "very awesome, body-empowered people, who were specific about what was comfortable or uncomfortable and whether we were in the right place." Tillman, as "The Feminist Midwife," now speaks and writes about trauma-informed practice and consent in pelvic care—topics that almost certainly would not have made it onto the schedule at the 1964 AMA meetings.
Alexandra walks her first group of nurse practitioner students through the pelvic exam, focusing equally on technique and communication. Like Magee, she reminds her audience that it is important to tell people who is doing what, where, and why at every step. Language matters: it's a "table," not a "bed," and a "drape," not a "sheet." They will "place" rather than "insert" things into the vagina, which may not be called a vagina by a transmasculine or nonbinary patient; in that case, use the term the patient uses. When the first student visualizes the cervix, the others crowd around to peer through the speculum and the room fills with "oohs" and "aahs."
"Thank you," Alexandra says proudly. "It never gets old."
Further Reading
Wendy Kline, Bodies of Knowledge: Sexuality, Reproduction and Women's Health in the Second Wave (University of Chicago Press: Chicago and London, 2010)
Deirdre Cooper Owens, Medical Bondage: Race, Gender, and the Origins of American Gynecology (University of Georgia Press: Athens, 2017)
Kelly Underman, Feeling Medicine: How the Pelvic Exam Shapes Medical Training, (New York University Press: New York, 2020)
Image credit: Illustration from Operative gynecology, 1906 (Wikimedia Commons | Public Domain)
