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Solving a Medical School Dilemma: Who Wants to Be The Proctologist's Very First Patient?

By Richard Claflin

A Doctor's very first patient: The most important teacher you've probably never thought about.

Many years ago I found myself sitting in a doctor's waiting room with a sore throat. Perhaps influenced by a parenting magazine on the coffee table, suddenly an odd thought occurred to me: How do gynecologists and urologists learn to do invasive exams? Who do they practice on? Manikins? Is that even helpful? I thought, how do you practice a prostate exam? Does some unlucky patient wind up being the first attempt for a new doctor just out of school?

And...wouldn't it be awful to be that first patient?

To make a long, circuitous story very, very short, I find myself now training instructors to address that challenge. As I discovered, the problem of how to practice these sensitive exams creates a lot of anxiety for medical students, and hadn't been given much attention. I've spent the last several years committed to changing this.

Historically, it has been next to impossible to get anyone to volunteer to act as a "guinea pig" for untrained hands learning how to do the invasive, stigmatized, and emotionally complicated gynecological, urogenital, and prostate exams.

No surprise there.

Professors, understandably, won't allow their own bodies to be examined by students who need to practice. Likewise, students should not be required to practice on each other. Plastic manikins simply don't work: Their hard components don't accurately feel like the delicate structures, and manikins don't provide any immediate feedback. This is a huge drawback for a student who wants to learn how to perform these exams without hurting a patient in the process.

Some students have been made to practice on anesthetized patients. Some students still are. (Note: Always read the small print when you sign consent forms before going under general anesthesia.) To their credit, students and professors have strong moral objections to this practice...and, just like manikins, there is no feedback from an anesthetized patient.

But even if there was a willing volunteer, would that really work? There is so much emotional discomfort and social baggage involved when it comes to the private areas of the body, so much anxiety for the students, such a great possibility for injury to the volunteer, so little direction about what to say to a patient to make them comfortable, so much inconsistency in the methodology...and, aside from all that, no guarantee that an untrained volunteer will provide constructive feedback to the student. From the standpoint of a school, such a volunteer creates more problems than they solve.

The result is that many students get no hands-on training when learning to perform "bathing suit-area" exams. The thinking too often is that this whole area of instruction is too complicated, too embarrassing, too stigmatized, and too traumatizing. And therefore nothing is offered and nothing is done.

So, yes...you very well could be that first patient for a new doctor with inexperienced hands.

But there is a solution. What schools need are highly trained specialists who can instruct students as well as use their own bodies to allow students to practice the techniques. These specialists are called Gynecological Teaching Associates (GTAs) and Male Urogenital Teaching Associates (MUTAs). They are substitute professors, if you will, who teach the necessary exam skills and then also act as "patients" to guide the students as they practice those exam skills on that same instructor. Equally important, GTAs and MUTAs teach the students essential communication skills that help make the patient feel comfortable during the exam.

I didn't invent this idea; here and there schools have trained GTAs and MUTAs "in-house." But most schools don't have the wherewithal or the kinds of resources to recruit and train such high-level instructors. Most schools need an outside group to come to them with excellent GTA and MUTA instructors to provide standardized training for their students. Such outside groups have been rare or non-existent, until now. After many years of experience as a GTA, one of my current colleagues formed a company about a year ago to address this need. I quickly joined her to help develop a MUTA program and act as Managing Director and Lead Trainer for the company.

Finding instructors willing to do this was -- and is -- a challenge. Being a GTA or MUTA is hard work, physically and emotionally. In addition, there was virtually no information on how to train instructors. As we expanded our reach over the past year, I wound up having to write the only available curriculum to train MUTAs. My colleague, Isle Polonko, developed the curriculum to train GTAs. Our company, Clinical Practice Resources (ClinicalPracticeResources.com), now provides instructors to dozens of teaching hospitals, schools, and institutions throughout the country. We now have over 20 highly trained male and female instructors doing this important work, and we are the largest independent company in the world providing this kind of educational instruction. And yet, we barely feel we have scratched the surface.

The response from students and teaching institutions has been overwhelmingly positive, and we are continually getting referrals, requests to expand our program, develop new programs, and start programs in other areas of the country. There is a huge need for this kind of instruction. Over the last several years I have been invited to give presentations at international conferences by the Association of Standardized Patient Educators (ASPE), and have been invited again to give a number of presentations about my work at ASPE's annual conference this June. What started out as a random musing in my doctor's office one afternoon has certainly led me on a fascinating journey.

The most rewarding aspect of this work, though, was something I hadn't expected at all. Most of the students we teach are in the middle of medical school, and have spent their entire education up until that point immersed in books or interacting only with plastic manikins. When I teach a class, I am often the first real human "patient" they have yet to come in contact with. Students start the class filled with anxiety, terrified. By the end of my class, they are filled with confidence. This is, after all, what everything has been about for them: working with people. Because I've provided them with an anxiety-free way to conquer the scariest challenge so far in their medical training, they emerge fearless about the challenges that lay ahead for them...and excited to meet their future patients with care and empathy. It's a momentous transformation, and I am continually grateful to be a part of that accomplishment.

So, as it happens, I was wrong. For me, being that first patient for a young doctor turns out to be a wonderful experience.

For more information about his work, Richard Claflin can be reached at richardcprte@gmail.com. Or, through the website at ClinicalPracticeResources.com

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