Smear campaign

Who volunteers for a gynaecological exam? A group of women who are fed up with cack-handed doctors - and want to train them properly, says Geoff Watts

Paula Pheby, 25 and single, doesn't know how many gynaecological examinations she's had in the past year. She puts the number at well over 100. Jane Dent, a 48-year-old mother, is equally uncertain of her total - but reckons that it is even higher.

Paula Pheby, 25 and single, doesn't know how many gynaecological examinations she's had in the past year. She puts the number at well over 100. Jane Dent, a 48-year-old mother, is equally uncertain of her total - but reckons that it is even higher.

Neither woman is afflicted with some strange or baffling disease requiring frequent scrutiny. Far from it; both are in good health. Nor are they hypochondriacs in need of repeated reassurance. What Paula and Jane have in common is a part-time job. They are "gynaecological teaching associates", or GTAs. Their aim is to produce a generation of doctors who are better skilled and more sensitive towards their patients.

Few women enjoy pelvic examinations. Some, says Professor Andrew Calder, an obstetrician at the Centre for Reproductive Biology in Edinburgh, find them unpleasant to the point of distress. "I think there is a small group who fall into this category, probably fewer than 5 per cent," he says. "And doctors have not always been sensitive to the feelings of these individuals."

The Royal College of Obstetricians and Gynaecologists acknowledges the problem. Three years ago, Professor Calder served on the working party it convened to investigate the conduct of intimate examinations. "Some patients," says its report, "experience considerable distress, anger and confusion following such an examination and, despite making no formal complaints, may experience long-lasting difficulties arising from an unpleasant or traumatic examination." The report offered detailed guidelines not only on the procedure itself, but on everything from the use of chaperones to the provision of warm changing facilities.

But before such wisdom can be exercised it has to be learnt. And although today's students have fancy plastic and silicon models to practise on, sooner or later they have to make their first manual expedition into the nether regions of a real woman, who may be as nervous as they are.

Most teaching relies on the co-operation of ordinary patients. Women who are worried or embarrassed about being examined by a student can refuse. Even so, more women agree than not, says Janice Rymer, a senior lecturer in obstetrics at Guy's, King's and St Thomas' School of Medicine. While no patient is obliged to say yes, it's a fair bet that some who don't much like the idea none the less feel pressured to agree. And if they do, they could end up having this extremely personal examination conducted by someone as cack-handed as they are inexperienced.

The sex of the student is also an issue. Rymer asked one group of 170 women about this. She found that while 72 of them would agree to an examination being conducted by either sex, another 41 would agree only to female students.

One alternative is for students to practise their technique on women who are under general anaesthetic. This deals with the issue of distress - but has the obvious drawback that even the most ham-fisted approach won't provoke a warning yelp, let alone a howl of protest. Moreover, besides being denied the opportunity to learn that their technique is below par, the students also get no practice in communication.

Then, too, there are dark tales of women who have been examined without their permission - though this is rare. The rules where Rymer works, for example, are strict: students have to speak to patients pre-operatively, explain what will happen, and get their written consent.

With all these difficulties, exacerbated by the increasing number of students, Rymer wasn't happy. "We felt we weren't teaching our students how to do pelvic examinations very well." Hence the introduction of gynaecology teaching associates: women who teach the skills of pelvic examination using their own bodies. Already a feature of training in Australia, America and Scandinavia, the idea had never previously caught on in Britain. Rymer decided that its time had come.

She advertised for suitable women through notices in family planning clinics and GPs' surgeries. "We got about 50 applications. We ended up short-listing 10, and from them we chose six." Some of the applicants hadn't understood what it would entail, and a few were medically unsuitable - having had a hysterectomy, for example. But all in all, Rymer says, recruitment wasn't a problem.

Jane and Paula were both members of the original group. "The ads said something like: 'Are you interested in women's health? Are you comfortable with your own body?'," Jane recalls. She felt she was. "And the rate of pay was reasonably attractive." Both women guessed that the job was something gynaecological. Paula, at that time working in IT, was quite unfazed when the details of the scheme were revealed. In fact, she was excited at the prospect of doing something so different. Jane, on the other hand, was more doubtful. "I wasn't sure whether I'd be able to go through with it. But I thought, well, if I can't I'll just leave."

Although Paula, for one, hadn't been impressed by her own experiences of gynaecological examination, neither woman was driven by a crusading zeal. And Jane's initial interest was, to a great extent, practical. "It did say on the ad that the hours were flexible, and I can't work nine to five. I home educate my 10-year-old, and I like to find jobs that fit around him."

Rymer and two of her colleagues trained the GTAs. "We started with communication and teaching skills, and then we talked about anatomy and physiology and menstrual cycles and that sort of stuff. And after that we went through the technicalities of examination."

As it turned out, the GTAs themselves ended up formulating some of the finer details on how to deal with women about to examined, such as what to tell them and what manner to adopt. "We had a lot of discussion and role play to decide exactly how we, as women, would like to be treated," says Jane.

Having covered the theory, they used plastic models to learn the practical skills of pelvic examination. Then, still under the supervision of the doctors, they took turns at examining each other.

When working with students, the GTAs operate in pairs, one playing the role of patient, the other acting as supervisor. Teaching sessions last two-and-a-half hours, typically with four students per session.

When practising how to take a smear, the students learn to position the instrument but don't actually scrape the surface of the cervix. Even so, you might imagine that a succession of examinations could prove uncomfortable. Jane concedes that this can be the case, but only during an all-day session in which, for some reason, the same woman has to act as the examinee throughout.

Although few of Paula's friends know precisely what she does, her relatives do. "My mum, especially, feels it's a really valuable service." Jane, too, reports that her work gets full approval on the home front. "My husband's always been very supportive of anything I've wanted to do. In fact, he's proud of me for doing it."

According to Paula, the students' skills vary enormously, especially their skill at talking to patients. "Some of them are dreadful. But some are fantastic and barely need teaching." Many are extremely nervous. "And they're often embarrassed," adds Jane, "especially male students. You can see they're sweating and shaking."

The students often worry about hurting the women. But Jane and Paula are unconcerned: "We've come to recognise the signs when they're going to hurt us, so we can normally stop them before it happens." Surprisingly, perhaps, the abilities of the male and female students are quite similar - and both genders seem to value the scheme equally. Rymer describes their response as overwhelming. "Each time it's just unbelievably positive."

Rymer and her colleagues compared students who had been taught by GTAs with others who had had only conventional training. "The GTA group came out much better, both in technical and communication skills," says Rymer.

So what of the future of this exceptional approach to medical teaching? Rymer, at least, has the backing of her own local purse holders. "It's now in the curriculum and part of the medical school budget." The scheme was short-listed in the Bupa Foundation's annual award for new ideas on communication in medicine. London's Royal Free Hospital has also started to use GTAs, and some of the new medical schools are showing an interest. Rymer points out that actors playing the part of patients are used routinely nowadays to help doctors improve their communication skills. She sees this scheme as a natural progression.

The GTAs themselves maintain that they offer students something that "real" patients can't. "We've been trained to give feedback, and we're not afraid to do so," says Jane. "We're not nervous the way many women would be. We can also give them tips on not causing any pain. And we know what they're meant to be doing, whereas the average woman may not. We know that a smear test shouldn't hurt."

"And we know where our cervix is," adds Paula. "If the student is struggling to find it, we can help."

EASY DOES IT: TIPS FOR PATIENTS AND DOCTORS

PATIENT

* If you feel nervous, tell the doctor.

* If you're having a smear test, remember that a positive finding doesn't automatically mean you have cervical cancer; in fact, having regular smears may prevent you developing cancer.

* Ask the doctor to warm the speculum (the instrument used to take smears); this will make the test more comfortable for you.

* Empty your bladder if you need to; this will help to make the procedure easier on you. But first ask the doctor if this is OK.

* A gynaecological examination shouldn't hurt; if it does, then tell the doctor and she will stop.

DOCTOR

* Try to put yourself in the patient's shoes - and remember how you felt before you became a doctor. Medical examinations were probably a bit more daunting back then!

* Pick up on the patient's body language; she might not say if she is nervous, embarrassed or even petrified, but she will show it.

* Use positive language, and make sure the patient knows what's involved in the tests, and why you're doing them.

* Keep the patient covered up as much as possible and let her keep her shoes on. She will feel less exposed and will relax more. Just saying "relax" isn't enough!

* Be slow and gentle with the speculum.