With a blue paper sheet covering her pubic hair, a 30-year-old woman is lying naked from the waist down, with her legs spread open on an examination couch in a hospital room. A trainee doctor opens her vagina with a speculum and gazes inside to find the cervix.
But this is no ordinary pap smear. The woman being examined is in fact a teacher, and she's here to show the medical student how to do a gynecological exam which is painless and stress-free for a patient—by allowing them to practise on her own body.
The University of Oxford medical school is one of several which have pioneered a groundbreaking feminist way of teaching medical undergraduates gynecology, in which women from the general public are trained to teach medical students.
Many women dread cervical screening tests and similar examinations after having had less than comfortable experiences, both physically and emotionally. And vaginal exams are of course especially hard—sometimes traumatic—for women who have experienced rape or sexual abuse. One in three British women between 25-29 don't attend smear tests, often because of fears they are embarrassing or painful, which has led to a rise in cases of cervical cancer. The medical profession urgently needs to make these tests less daunting for women.
Oxford's medical school is trying to solve the problem by changing the way its students are educated.
Traditionally, medical students practise vaginal examinations on plastic models, but this is problematic. Plastic models are different from living bodies and don't have physical and emotional responses. A medical student using a speculum on a plastic vagina learns nothing about what could be painful or uncomfortable, nor about how to interact when doing such examinations with real women.
The history of how medical students have been taught gynecology is shady—as recently as the 1990s, anesthetized women undergoing operations were routinely used as guinea pigs for students to practice vaginal exams, without their knowledge or consent. Today, of course, says Jane Moore, a consultant gynecologist at the med school and the leader of its laywomen training program, this is viewed with horror "as shameful exploitation." Instead, students usually practise on plastic models or consenting patients anesthetized during gynecological operations.
But overall, she stresses, "You cannot learn to do a competent examination on a plastic model that feels nothing like a person. And you cannot learn to do a sensitive examination on a person who is anesthetized."
Wanting to improve the education of medical students and make it more patient-friendly, and aware of how difficult many women find visiting their gynecologist, Oxford's medical school started recruiting what they call "laywomen" to teach medical students—people who are effectively both teacher and model.
Many women from all walks of life respond to the medical school's advertisements, although some drop out during the training process, which involves discussing the relevant issues, observing other laywomen running sessions, and practising being examined without a student present. The current team of six laypeople range in age from early 20s to late 50s; they work in fields ranging from welfare to the arts. Most have degrees and some are mothers.
It is a little unusual at first, but it's amazing how quickly it becomes normal.
Working in pairs, each typically does six two-hour evening teaching sessions for medical students in a three week block, and then has five weeks off before starting another block. They are paid for their time at a similar rate to a university lecturer, and they are also paid for their hours of intensive training for this challenging role.
Although laywomen teaching gynecology students has been common practice in the US for many years, it has only taken off in the UK over the last decade—around half the medical schools in the UK now teach in this way. But Oxford, which began its program ten years ago, is the first school in the UK to have its students not only trained by laywomen, but also formally assessed by them as part of their final exams. Only when the laywoman signs the medical student off as competent can the student get their pass.
Today, two young and rather nervous looking male medical students—Dan and Tom*, both 23—are being taught by Sally*, a 30-year-old woman who works in academic publishing, and Benny, a genderqueer 31-year-old counselor and psychology student.
Most of the session takes the form of role-play. First, Benny plays the doctor and Sally the patient while the students watch. Benny demonstrates how to discuss a smear test and internal exam with a patient sensitively—showing her the speculum; discussing previous bad experiences if she raises them; asking for her consent; explaining she can ask the exam to stop at any moment. Benny explains: "You might have a patient putting on a brave face who's actually terrified."
Next, Benny examines Sally using a speculum, then does manual vaginal and abdominal exams, all with the students watching closely. They learn the "gold standard" of respect in this situation—locking the door to the consulting room so others can't wander in; using the speculum expertly and with plenty of lubrication; not "prodding and poking" the cervix; stopping if there is any discomfort.
They learn to ensure the patient is never left feeling "exposed"—uncovered with her legs uncomfortably splayed—while the doctor prepares their tools, and to raise the couch so the doctor doesn't appear to "tower over" the woman. And never to move the blue paper sheet but to ask the woman to move it herself; to warn her before they touch her, and check repeatedly that she is comfortable. And that a small speculum is often "more comfortable and works just as well" as the medium one doctors tend to default to, and to listen if a woman asks for a small speculum.
Then it's the students' turn: Dan examines Sally, and Tom examines Benny. They seem a little awkward—after all, they wouldn't usually see a teacher's private parts, let alone do an intimate examination on one within an hour of first meeting. But with warmth and jokes from Benny and Sally, the young men relax.
I walk out of the door feeling I've made the world a better, more feminist place.
They are model trainees and have internalized all they have been taught. They only fall into a few traps, like when Tom unthinkingly says, "I'm going to ask you to lift your top up and have a feel" before performing an abdominal exam. Doctors cannot be too careful when it comes to language, Sally and Benny gently emphasize.
Does it feel weird being examined by total strangers? Not really. Benny is body-confident and, they add, "impossible to embarrass."
"It is a little unusual at first, but it's amazing how quickly it becomes normal," says Sally, who has always had an interest in women's health. When she first observed another laywoman leading training, she recalls, she hung back. "I didn't want to intrude unnecessarily and possibly make the woman uncomfortable," she says. "It was a flash of uncertainty about what was expected or appropriate for me to do in this setting." But the woman beckoned her over to learn as the others did, and Sally then realized how at ease the woman was.
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Sally and Benny have never felt unsafe with any student so far, but if they ever do, they can halt the teaching session at any time. They have become used to calling out "Pause!" when examinations become uncomfortable, an assertiveness which they also transfer to their real-life patient experiences.
"The crucial thing is that [this teaching] gives the patient's voice authority, right from the start of medical training," says Jane Moore. "If the patient is your teacher from the start, it's more difficult to unlearn that."
Oxford is also rolling out other patient-led medical teaching—women who have miscarried teaching students about miscarriage; a transgender person lecturing on their experiences.
"Patients are the authorities on their own bodies and when you're being examined, you're the teacher," says Benny. "That's a weirdly powerful dynamic shift. And I walk out of the door feeling I've made the world a better, more feminist place."
* Name has been changed. All photos by Alice Zoo.